- See:
Peroneus
Longus /
Peroneus Brevis:
- Discussion:
- acute dislocation occurs by sudden forced dorsiflexion w/ concomitant
eccentric contraction of the
peroneal muscles;
- classic teaching that the tendon dislocation occurs from a
combination of dorsiflexion and eversion
(like
skiing), where as other authors feel that the injury occurs from dorsiflexion
and inversion
(which accounts for its association with ankle instability);
- chronic peroneal tendon dislocation is often associated w/ recurrent
ankle sprains
of peroneal retinaculum, and subsequent tendon
subluxation;
- patho-anatomy:
- at the level of the ankle joint, the peroneal tendons lie in a
groove in the posterior fibula;
- grove is present in (82%) fibulas, a transverse flat surface
in 19 (11%), and a convex surface in 13 (7%);
- average width of sulcus, when present, is 6 mm;
- lateral border of the posterior fibular surface may form a
bony ridge (2-4 mm) augmenting the sulcus;
- peroneus longus courses posterior to the brevis tendon, and then
both tendons pass thru the common
peroneal synovial sheath, about 4 cm proximal to the lateral malleolus;
- synovial sheath passess through a fibro-osseous tunnel that is
stabilized by the superior peroneal
retinaculum and by calcaneofibular ligament;
- superior peroneal retinaculum:
- primary constraint to peroneal tendon subluxation;
- retinaculum is formed as a confluence of superficial fascia,
and sheath of peroneal tendons, and
periosteum of distal fibula (about 2 cm proximal to fibula tip);
- formed from thickening of fascia that arises off the
posterior margin of distal 1-2 cm of the fibula and
runs posteriorly to blend with the Achilles tendon sheath.
- synovial sheath passes behind the distal fibula (retromalleolar
sulcus), and the depth of the sulcus may
be related
to propensity for peroneal subluxation;
- w/ peroneal tendon dislocation there is stripping of the periosteum
from the lateral malleolus which is
in
continuity w/ superior peroneal retinaculum;
- result is the creation of a false pouch posteriorly (similar
to the false pouch created by a shoulder
Bankhart lesion);
- associated findings:
-
anterolateral instability of the ankle is associated with laxity of the
superior peroneal retinaculum;
- superior peroneal retinaculum is a secondary constraint to
anterolateral ankle instability;
- degenrative changes and longitudinal splitting in the peroneus
brevis tendon;
- Exam:
- there will be tenderness posterior to the lateral malleolus;
- subluxation of the peroneal tendons may be provoked by having the patient
dorsiflex the foot from a position
of dorsiflexion and eversion;
- look for a prominence of the tendon w/ dorsiflexion and internal rotation;;
- w/ chronic peroneal tendon subluxation, there will often be signs of ankle
instability;
- w/ a questionable exam, consider a diagnostic lidocaine injection into the
peroneal tendon sheath;
Imaging:
- need to assess mortise view of the ankle;
- look for shell-like avulsion fracture of the lateral malleolus (which
indicates disruption of the peroneal
retinaculum) and dislocation of the peroneal tendons;
- Tenograms and CT may be used, but MRI is of greatest value in evaluating
soft tissue structures
- Non Operative Treatment:
- ensure that the tendons are reduced before immobilization;
- place in plantar flexion in slightly inverted below knee cast for 6 wks
- note that conservative treatment for acute injuries in active young
athletes, generally has a relatively high
recurrence rate (50%);
- Surgical Treatment::
- in active patients, surgical fixation of the disrupted sheath is treatment
of choice.
- Surgical Options: peroneal groove deepening, tenoplasty, or bone block;
*- Groove Deepening with SPR repair
- if performed with care can preserve the periosteal flaps
and help secure tendon sheath to posterior
fibula
- Kolias and Ferkel (Am J Sports Med 1997) 95% success ratee
- Mendicino et al (J Foot & Ankle Surg 2001) 100%
success rate
- Surgical Technique: (Click on picture to the right to view
movie of this procedure)
- osteotomize distal posterior fibula leaving medial
side hinged
- curette underlying cancellous bone
- reinsert flap into deepened bed
- Advantages
- correct groove deficiency
- maintain cartilaginous gliding layer
- rare recurrence, all reinforced SPR simultaneously
- Disadvantages
- tendon irritation on bony edges, failure to correct
dislocation pouch
- tenodesis should be performed 3-4 cm above the fibular tip and 5-6
cm below the fibular tip;
- in the Singapore operation, the false pouch is obliterated by
suturing down the superior retinaculum to
the
posterior fibula;
- a secure repair, requires drill holes to be made in the distal
fibula;;
- in some cases, a slip of Achilles tendon may be required to
augment the repair;
- hazards: note that the sural nerve lies about 1 cm distal to the
distal end of the fibula;
Tendon injuries about the ankle resulting from skiing.
Static or dynamic repair of chronic lateral ankle instability. A prospective
randomized study.
Recurrent dislocation of the peroneal tendon.
Traumatic dislocations of the peroneal tendons. Arrowsmith SR, Fleming LL,
Allman FL: Am J Sports Med 1983;11:142.
Acute rupture of the peroneal retinaculum. Eckert WR, Davis EA: J Bone Joint
Surg 1976;58A:670-673.
Dislocation of the peroneal tendons long term surgical treatment. Escalas F,
Figueras JM, Merino JA: J Bone Joint Surg 1980;62A:451-453.
Dislocation of the peroneal tendons. Marti R: Am J Sports Med 1977;5:19-22.
Sliding fibular graft repair for chronic dislocation of the peroneal tendons.
Micheli LJ, Waters PM, Sanders DP: Am J Sports Med 1989;17:68-71.
Ankle injuries in skiing. RE Leach and G Lower. CORR. Vol 198. 1985. p
127-133.
Peroneal tendon injuries. HD Clarke MD et al. Foot and Ankle Internation.
Vol 19. No 5. May 1998. p 281.
Traumatic Peroneal Tendon Instability Rhett B. Mason and Ian J. P. Henderson.
American Journal of Sports Medicine. Vol 24 No 5 Sep - October 1996
Superior peroneal retinaculoplasty: a surgical technique for peroneal
subluxation.
Current Concepts Review: Peroneal Tendon Subluxation and Dislocation