The peroneal groove deepening procedure: a biomechanical study of pressure reduction

The Ankle Ligament Reconstruction-Return to Sport after Injury (ALR-RSI) is a valid and reliable measure to assess psychological readiness before returning to sport following peroneal tendon pathology surgery

PURPOSE

The objective of this study was to validate a scale that could help surgeons evaluate patients' psychological readiness to return to sport (RTS) after peroneal tendon pathology surgery.

METHODS

The Ankle Ligament Reconstruction-Return to Sport after Injury (ALR-RSI) scale, which had previously been validated in ankle ligament reconstruction patients, was adapted to evaluate the psychological preparedness for RTS in athletic patients who underwent peroneal tendinopathy surgery. The Foot and Ankle Outcome Score (FAOS) and Foot Ankle Ability Measurement (FAAM) scores were employed as patient-related outcome measurement (PROM) instruments.

RESULTS

This study included 57 patients. There was a strong correlation between ALR-RSI and both FAOS and FAAM (r = -0.68 and 0.74, respectively). ALR-RSI was considerably higher in patients who returned to sports than in those who did not. The mean score was 72.9 ± 19.0 in patients who returned to the same preinjury level, 48.5 ± 24.0 in those who returned to a lower level and 53.6 ± 31.1 in patients who changed their athletic activity (p < 0.0001). Furthermore, ALR-RSI showed at least a similar discrimination ability when compared to FAOS and FAAM. The test-retest intraclass correlation coefficient was 0.95. The Cronbach's α statistic used to measure the internal consistency was high (0.95). A Youden index of 0.65 was observed for a cut-off score of 68 points.

CONCLUSION

ALR-RSI is a valid instrument for assessing psychological readiness to RTS in an athletic population following peroneal tendon surgery. When compared to the most commonly used PROMs, it was strongly correlated and demonstrated at least similar discrimination capacity. This could assist surgeons in identifying athletes who will have poor postoperative results and advising them on their capability to RTS.

LEVEL OF EVIDENCE

Level III.

Snapping ankles: peroneal tendon subluxation and dislocation

Peroneal tendon dislocation or subluxation is an orthopaedic condition that usually occurs as a result of injury to the superior peroneal retinaculum. The peroneal muscles are located in the lateral compartment of the leg, and their tendons run in the retromalleolar groove anchored by the superior peroneal retinaculum. Peroneal instability is usually classified using the Eckert and Davies classification, which was modified by Oden into a four-point grading system. The mechanism of injury is typically sudden forced dorsiflexion, resulting in aggressive tautness of the peroneal tendons, combined with a forced eversion of the hindfoot. Plain X-ray, ultrasound and magnetic resonance imaging are useful for imaging of the injury and in planning for surgery. Operative management has high success rates and there are multiple surgical techniques available, including superior peroneal retinaculum repair, tenoplasty, bone block procedures, groove deepening and endoscopic approaches, with little variation in outcome found between the approaches.

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.

Endoscopic Superior Peroneal Retinaculum Reconstruction Using Q-FIX MINI Suture Anchor

Post-traumatic peroneal tendon subluxation or dislocation is most commonly caused by injury to the superior peroneal retinaculum. Classic open surgeries usually require extensive soft-tissue dissection and have potential risks of peritendinous fibrous adhesions, sural nerve injury, limited range of movement, recurrent or persistent peroneal tendon instability, and tendon irritation. The purpose of this Technical Note is to describe the details of endoscopic superior peroneal retinaculum reconstruction using Q-FIX MINI suture anchor. This endoscopic approach has the advantages of minimally invasive surgery, including better cosmesis, less soft-tissue dissection, less postoperative pain, less peritendinous fibrosis, and less subjective tightness at peroneal tendons. Insertion of the Q-FIX MINI suture anchor can be performed inside a drill guide, and trapping of the surrounding soft tissue can be avoided.

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

»

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

»

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

»

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.

The vascularization of the peroneal tendons: An anatomic study

BACKGROUND

Arterial vascularization is intimately related to the peroneal tendon ruptures. Our purpose is to describe the vascular anatomy of peroneal tendons and assess differences in the vascularization patterns between peroneus brevis tendon (PBT) and peroneus longus tendon (PLT).

METHODS

Anatomical study of 22 cadaveric lower extremities. We exposed tendons' vascularization by injecting latex. To systematize the vascular description, we considered four anatomical regions in the PBT and six in the PLT.

RESULTS

Vascularization was supplied by the peroneal, anterior tibial and lateral plantar arteries and from the deep plantar arch through the vincula connecting the tendons. No avascular areas were found in the PLT. 22.7% of specimens had avascular areas in the PBT. Two visual vascularization patterns were found (arcuate and weblike). Increasing age and a web-like vascularization were associated with a lower number of blood vessels at the tendons' post malleolus area.

CONCLUSION

Peroneal tendons are well vascularized throughout their course, running through a common vincula, with vascularization provided by various arteries. Avascular areas were observed in the PBT, but none at the PLT.

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.

Posterior Fibular Groove Deepening Procedure With Low-Profile Screw Fixation of Fibrocartilaginous Flap for Chronic Peroneal Tendon Dislocation

Chronic peroneal tendon dislocation is an uncommon disorder that frequently presents with concomitant pathology. Posterior fibular groove deepening and retinaculum repair have been increasing in popularity for treatment of peroneal tendon dislocations. The purpose of the present study was to introduce a posterior fibular groove deepening procedure using low-profile snap-off screws to securely and simply fix the fibrocartilaginous flap to facilitate faster rehabilitation and to assess the clinical outcomes of patients with chronic peroneal tendon dislocation and associated pathologic features. In the present retrospective case series, 34 ankles in 34 patients underwent the fibular groove deepening procedure using low-profile screws with superior peroneal retinaculum repair. The clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and patient subjective satisfaction rate. The time of return to recreational and sports activities was also assessed. Weightbearing ankle radiographs were evaluated to assess the stability of the flap by checking the screws. The mean follow-up period was 47.96 (range 12 to 142) months. The mean AOFAS scale score for all patients improved from 69.96 ± 13.14 to 87.72 ± 10.13 at the last follow-up examination (p < .001). Overall, 85.3% of patients subjectively rated their operative outcomes as excellent or good. The 18 (52.9%) patients with an isolated peroneal tendon dislocation had a faster return to recreational or sports activities than the 16 (47.1%) patients with concomitant pathologic features (2.95 ± 0.19 versus 4.14 ± 1.34 months; p = .002). No patient experienced residual dislocation, screw loosening, or irritation from the screws. The fibular groove deepening procedure using low-profile screws is be a simple procedure that offers rigid fixation. This leads to relatively fast rehabilitation and resumption of recreational or sports activities.

Endoscopic Superior Peroneal Retinaculum Reconstruction

Post-traumatic peroneal tendon subluxation or dislocation is most commonly due to injury to the superior peroneal retinaculum. Acute repair of the retinaculum is an option for active athletes who desire quick return of sport activity. In general, conventional open surgeries require extensive exposure of the injured superficial peroneal retinaculum and have potential risks of scar formation, sural nerve injury, limited range of movement, peroneal tendon re-subluxation, and tendon irritation. The purpose of this Technical Note is to describe the details of endoscopic superior peroneal retinaculum reconstruction. This has the advantages of minimally invasive surgery of better cosmesis, less soft tissue dissection, less postoperative pain, less peritendinous fibrosis, and less subjective tightness at peroneal tendons. The endoscopic view allows better assessment of retinaculum integrity, grading of injury, and detection of coexisting pathology.

Endoscopic fibular groove deepening for stabilisation of recurrent peroneal tendons instability in a patient with open physes

This is a report of a rare case of recurrent traumatic peroneal tendon dislocation in a patient with open physes. Through fibular tendon endoscopy, an intramuscular needle was introduced under direct visualisation and implanted inferiorly to the growth plate while reclining the tendons posteriorly. A fibular groove deepening was performed in order to stabilize the tendons. The patient was able to return to full activity after 3 months. MRI taken 12 months after surgery showed neither signs of recurrence of the lesion nor growth plate disturbance. This is a first case report of peroneal tendons stabilisation by tendoscopic retro-malleolar groove deepening in a child. Level of evidence Case report, Level IV.

Retromalleolar Groove Deepening in Recurrent Peroneal Tendon Dislocation: Technique Tip

Peroneal tendon dislocations are most prevalent in the active and athletic population, so accurate diagnosis and management are essential for optimal return of function. Although many nonoperative and surgical management options have been described, the optimal treatment method continues to be debated. In this technique article, a modified retromalleolar groove-deepening technique is described for addressing all anatomic variations of the posterior distal fibula and retromalleolar groove without unduly disturbing the important anatomic facets meant for retention in this region. This technique is indicated for chronic dislocated peroneal tendons, recurrent dislocating peroneal tendons, and dislocation of the tendons after acute injury with a shallow fibular peroneal groove. Although it remains unclear what effect a cortically abraded fibular gliding surface or forceful cortical impaction on the fibrocartilage gliding surface might have on peroneal tendon integrity and function long term, it would seem preferable to avoid such techniques if reliable alternatives are available.

Functional outcomes after peroneal tendoscopy in the treatment of peroneal tendon disorders

PURPOSE

The primary purpose of this study was to evaluate clinical outcomes following peroneal tendoscopy for the treatment of peroneal pathology. Correlation between pre-operative magnetic resonance imaging (MRI) and peroneal tendoscopic diagnostic findings was also assessed.

METHODS

Twenty-three patients with a mean age of 34 ± 8.8 years undergoing peroneal tendoscopy were pre- and post-operatively assessed with the foot and ankle outcome score (FAOS) and the Short Form-12 (SF-12) outcome questionnaires. Follow-up was over 24 months in all patients. The sensitivity and specificity of MRI were calculated in comparison with peroneal tendoscopy, including the positive predictive value (PPV).

RESULTS

Both the FAOS and the SF-12 improved significantly (p < 0.05) at a mean follow-up of 33 ± 7.3 months significantly. MRI showed an overall sensitivity of 0.90 (95% confidence interval (CI) = 0.82-0.95) and specificity of 0.72 (95% CI 0.62-0.80). The PPV for MRI diagnosis of peroneal tendon pathology was 0.76 (95% CI 0.68-0.83).

CONCLUSIONS

The current study found good clinical outcomes in patients with peroneal tendon disorders, treated with peroneal tendoscopy. Although a relatively small number of patients were included, the study suggests good correlation between tendoscopic findings and pre-operative MRI findings of peroneal tendon pathology, supporting the use of MRI as a useful diagnostic modality for suspected peroneal tendon disorders.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Return to sports and clinical outcomes in patients treated for peroneal tendon dislocation: a systematic review

PURPOSE

The aim of this study was to determine the outcome following different surgical treatment techniques in the treatment of peroneal tendon dislocation and to establish whether return to sports was achieved universally following the procedures.

METHODS

A systematic review and best-evidence synthesis was performed. PubMed and EMBASE were searched for eligible studies. The last search was done in March 2015. Quality assessment of pooled data was performed using a modified Macleod scale and a best-evidence synthesis was performed. In total, 14 studies were included.

RESULTS

Surgical treatment provides improvement in the post-operative AOFAS score (p < 0.0001) and high satisfaction rates. The redislocation rate is less than 1.5% at long-term follow-up. Patients treated with both groove deepening and SPR repair have higher rates of return to sports than patients treated with SPR repair alone (p = 0.022).

CONCLUSIONS

Surgical treatment of peroneal tendon dislocation provides good outcomes, high satisfaction and a quick return to sports. Rates in return to sports are significantly higher in patients treated with both groove deepening and SPR repair. To optimize treatment, the surgical management should involve increasing the superior peroneal tunnel volume by groove deepening and stabilizing the tendons by SPR repair.

LEVEL OF EVIDENCE

Level IV, systematic review of level IV studies.

Peroneal tendons well vascularized: results from a cadaveric study

PURPOSE

Peroneal tendon tears are relatively common injuries that seem to have a poor healing tendency. The discussion goes that peroneal tendons have avascular zones, contributing to the poor healing of those tears. The purpose of this study was to provide evidence on the vascularization pattern of the peroneal tendons.

METHODS

Ten adult fresh-frozen cadavers were obtained from a university-affiliated body donation programme. The femoral artery was injected with natural coloured latex at the level of the knee. Macroscopic and microscopic dissections were performed to visualize the vascularization towards the peroneal tendons. To expose intratendinous vascularity, the tendons were cleared using a modified Spälteholz technique.

RESULTS

In all specimens, blood was mainly supplied by the peroneal artery through a posterolateral vincula connecting both tendons. Branches were bifurcated every 3.9 ± 1.8 cm, starting 24 ± 5.3 cm proximal to the tip of the fibula. Eight out of 10 (80%) specimens had poor vascularized zones in the peroneus longus tendon. No avascular zones were found in the peroneus brevis tendon.

CONCLUSION

The peroneal tendons are well vascularized by the peroneal artery, via vessels running through a common vincula for both tendons. In the peroneus brevis, no avascular zones were found. To keep the tendons well vascularized and therefore improve tendon healing, surgeons should be careful leaving the vincula intact during surgical procedures.

Peroneal tendoscopy

Peroneal tendoscopy is indicated for peroneal tenosynovitis, subluxation or dislocation, snapping, partial tears requiring debridement, and postoperative adhesions and scarring. Peroneal tendoscopy was also found to be valuable as a diagnostic tool in some instances. It is generally reported to have good to excellent outcomes in most patients with a relatively low occurrence of complications.

Reversal of Peroneal Tenodesis With Allograft Reconstruction of the Peroneus Brevis and Longus: Case Report and Surgical Technique

Chronic peroneal tendinopathy and tears represent a challenging clinical situation. Traditionally, tenodesis of the torn tendon to the remaining healthy tendon has been advocated if more than half of the tendon is compromised. Allograft reconstructions have been reserved for patients with functional muscles and both peroneal tendons extensively compromised. We report a unique case of a peroneal tenodesis takedown and reconstruction of both peroneal tendons using semitendinosus allograft. A description of the surgical technique and tips are provided. Peroneal tendon function is crucial to maintain a balanced hindfoot. To the best of our knowledge, reconstruction of both peroneal tendons after a tenodesis has not been previously reported. Allograft reconstruction of the peroneal tendons arises as a feasible alternative in patients with residual pain and weakness after a failed tenodesis surgery LEVELS OF EVIDENCE: Therapeutic Level IV, case study.

Comparison of Outcome After Retinaculum Repair With and Without Fibular Groove Deepening for Recurrent Dislocation of the Peroneal Tendons

BACKGROUND

This study compared the operative outcome between retinaculum repair with and without fibular groove deepening for the treatment of recurrent traumatic peroneal tendon dislocation in young, active patients.

METHODS

A consecutive series of 29 patients who underwent operative treatment of recurrent peroneal tendon dislocation were evaluated. Thirteen patients were treated by the superior peroneal retinaculum repair with fibular groove deepening (group A) and 16 patients by superior peroneal retinaculum repair alone (group B). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) score for pain, and overall patient satisfaction were used to evaluate the clinical outcome after a minimum follow-up period of 12 months postoperatively. In addition, mean time to return to sports activity and tourniquet time were compared between groups.

RESULTS

Mean AOFAS score improved significantly from 59.3 points preoperatively to 92.2 points at the final follow-up in group A and from 58.5 points preoperatively to 91.3 points at the final follow-up in group B. Mean VAS score also improved significantly from 5.0 points preoperatively to 1.0 points at the final follow-up in group A and from 4.9 points preoperatively to 1.2 points at the final follow-up in group B. Improvements in AOFAS and VAS scores at the final follow-up were not significantly different between the 2 groups. Mean time to return to sports activity was approximately 3 months in both groups. Mean tourniquet time in group B was significantly shorter than that in group A (42.2 vs 29.5 min).

CONCLUSIONS

Isolated retinaculum repair compared to retinaculum repair with fibular groove deepening was a faster and simpler technique, but both techniques had good outcomes for the treatment of recurrent traumatic peroneal tendon dislocation.

LEVEL OF EVIDENCE

Level II, prospective, nonrandomized, comparative study.

Endoscopic management of recalcitrant retrofibular pain without peroneal tendon subluxation or dislocation

Peroneal tendon pathology is not uncommonly encountered behind the lateral malleolus and presented as retrofibular pain. The three primary categories of peroneal tendon disorders include tendinitis and tenosynovitis, tendon subluxation and dislocation, and tendon tears and ruptures. We described an approach of endoscopic groove deepening and endoscopic assisted repair of longitudinal peroneal tendon tears in management of recalcitrant retrofibular pain without peroneal tendon subluxation or dislocation.

Intrasheath subluxation of the peroneal tendons

BACKGROUND

Dislocation or subluxation of the peroneal tendons out of the peroneal groove under a torn or avulsed superior peroneal retinaculum has been well described. We identified a new subgroup of patients with intrasheath subluxation of these tendons within the peroneal groove and with an otherwise intact retinaculum.

METHODS

The cases of fifty-seven patients with painful snapping of the peroneal tendons posterior to the fibula were reviewed. Of these, forty-three had tendons that could be reproducibly subluxated out of the groove with a dorsiflexion-eversion maneuver of the ankle. Fourteen patients who could not subluxate the tendons out of the groove underwent a dynamic ultrasound examination of the tendons. While the same dorsiflexion and eversion maneuver was being performed, the tendons were seen to switch their relative positions (the peroneus longus came to lie deep to the peroneus brevis tendon) with a reproducible painful click. All fourteen patients underwent a peroneal groove-deepening procedure with retinacular reefing. Intraoperatively, thirteen patients were found to have a convex peroneal groove and all fourteen had an intact peroneal retinaculum. All patients subsequently underwent a follow-up dynamic ultrasound examination and an American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score evaluation at a minimum of twenty-four months after surgery.

RESULTS

All fourteen patients were female, with an average age of thirty-five years. Two subtypes of intrasheath subluxation were found. Type A (ten patients) involved intact tendons with relative switching of their anatomic alignment. Type B (four patients) involved a longitudinal split within the peroneus brevis tendon through which the longus tendon subluxated. Intraoperative confirmation of the ultrasound findings was 100%. At an average follow-up interval of thirty-three months, the average AOFAS score had improved from 61 points preoperatively to 93 points, and the average score on the 10-cm visual analog pain scale had improved from 6.8 to 1.2. Follow-up ultrasound evaluation revealed healed tendons without persistent subluxation in thirteen patients. Nine patients rated the result as excellent, four rated it as good, and one rated it as fair.

CONCLUSIONS

Patients with retrofibular pain and clicking of the peroneal tendons may not have demonstrable subluxation on physical examination and may have an intact superior peroneal retinaculum. They may have an intrasheath subluxation of the peroneal tendons, which can be confirmed with use of a dynamic ultrasound. Surgical repair of tendon tears combined with a peroneal groove-deepening procedure with retinacular reefing is a reproducibly effective procedure for this condition.

Acute peroneal tendon tears

Acute peroneal tendon tears lay at one end of a spectrum of peroneal tendon pathology. Because a tear represents a mechanical abnormality, surgical treatment is frequently required. Anatomical variants need to be considered as potential causes of lateral ankle pain. Most acute peroneus brevis tears are longitudinal, occur adjacent to the tip of the fibula, and require surgical treatment. Acute peroneus longus tears more commonly occur at the level of the cuboid tunnel and may initially be managed nonoperatively, but, if associated with stenosing tendonitis, may require debridement and tenodesis. Rarely, complete ruptures of both peronei occur and, if there is a significant defect, reconstructive procedures are required.

Anatomic variants associated with peroneal tendon disorders: MR imaging findings in volunteers with asymptomatic ankles

PURPOSE

To evaluate prospectively, on magnetic resonance (MR) images in volunteers with asymptomatic ankles, various features of anatomic variants that are potentially associated with peroneal tendon disorders.

MATERIALS AND METHODS

The study had institutional review board approval; informed consent was obtained from each volunteer. The prevalence of accessory peroneus quartus muscles, the location of the muscle-tendon junction of the peroneus brevis muscle, the prevalence and size of the peroneal tubercle and the retrotrochlear eminence, and the shape of the retromalleolar fibular groove were evaluated on MR images in 65 volunteers with asymptomatic ankles (35 women, 30 men; age range, 23-70 years; median age, 45 years). MR images were analyzed by two radiologists in consensus. The relationship between anatomic features and age and sex was analyzed by using Spearman rank correlation and the Wilcoxon rank sum test.

RESULTS

A peroneus quartus muscle was identified in 11 (17%) ankles. Ninety percent of the musculotendinous junctions of the peroneus brevis muscle were located in a range between 27 mm proximal to and 13 mm distal to the fibular tip (median, 0 mm). A peroneal tubercle was identified in 36 (55%) ankles. Ninety percent of all peroneal tubercles were 4.6 mm or smaller (median height, 2.9 mm). A retrotrochlear eminence was seen in all ankles (median, 3.0 mm; 90% were 4.6 mm or smaller). The retromalleolar groove was concave in 18 (28%), flat in 28 (43%), convex in 12 (18%), and irregular in seven (11%) volunteers. A significant difference (P = .04) for the height of the retrotrochlear eminence was found between men (median, 3.4 mm) and women (median, 2.5 mm). All other P values were greater than .05.

CONCLUSION

Anatomic variants thought to predispose individuals to peroneal tendon disorders can be seen in volunteers with asymptomatic ankles.

Peroneal tendon tears: return to sports after operative treatment

BACKGROUND

Operative treatment has become the standard for peroneal tendon tears when nonoperative management fails. Successful return to sports has been reported in previous studies. We evaluated 30 patients who had operative treatment of peroneal tears.

METHODS

Patients who were evaluated by a questionnaire and by review of medical records, MRI, radiographs, and operative reports.

RESULTS

Nine of the 10 patients who were working outside the home were able to return to employment at the same level. A substantial number had residual symptoms, including scar tenderness (58%) and lateral ankle swelling (54%). Only 46% were able to successfully return to sports.

CONCLUSIONS

Although operative treatment was very effective in allowing patients to return to work, only half of our patients were able to return to sports at an average followup of 31 months.