Peroneal Retinaculoplasty with Anchors for Peroneal Tendon

Bulletin of the Hospital for Joint Diseases
Volume 63, Numbers 3 & 4
2006
113
Peroneal Retinaculoplasty with Anchors for
Peroneal Tendon Subluxation
Francesco Oliva, M.D., Nicholas Ferran, M.R.C.S., and
Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Ortho)
Abstract
Recurrent subluxation of the peroneal tendons is rare but
can produce marked functional impairment in athletes.
We describe a technique for the reconstruction of the
superior peroneal retinaculum using anchors. This procedure is safe and effective in managing instability.
T
he peroneal tendons share a common tendon
sheath proximal to the distal tip of the fibula with
the peroneus brevis medial and anterior to the
peroneus longus. More distally, each tendon lies in its
own sheath. The common sheath is contained within a
sulcus, the fibular groove, on the posterolateral aspect of
the fibula, preventing subluxation. The groove is 5 to 10
mm wide and up to 3 mm deep.1 The primary restraint to
tendon subluxation is the superior peroneal retinaculum.
This fibrous band originates on the posterolateral aspect
of the fibula and inserts onto the lateral surface of the
calcaneus. It is 10 to 20 mm wide, is reinforced superficially by transverse fibers, and courses in a posteroinferior direction, although variants in width, thickness,
and insertional patterns are not uncommon.1 The inferior
peroneal retinaculum is attached to the peroneal trochlea
and calcaneus above and below the peroneal tendons.
Acute traumatic subluxation of the peroneal tendons
Francesco Oliva, M.D., is in the Department of Orthopaedics
and Traumatology, University of Rome “Tor Vergata,” Faculty of
Medicine and Surgery, Rome, Italy. Nicholas Ferran, M.R.C.S.,
and Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Orth), are in the
Department of Trauma and Orthopaedic Surgery, Keele University
School of Medicine, North Staffordshire Hospital, Stoke on Trent,
Staffordshire, England.
Correspondence: Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Ortho),
Department of Trauma and Orthopaedic Surgery, Keele University
School of Medicine, Hartshill, Thornburrow Drive, Stoke-on-Trent,
Staffordshire, United Kingdom, ST4 7QB.
is uncommon.2 Acute injuries to the superior peroneal
retinaculum can be initially managed conservatively with
immobilization in a non-weightbearing cast,2 which has
a reported success rate of approximately 50%.2,3
In chronic subluxation, patients often reveal a history
of previous ankle injury that, in some cases, may have
been misdiagnosed as a sprain. An unstable ankle that
gives way or that is associated with a popping or snapping sensation is another common complaint. Chronic
subluxation of the peroneal tendons may be traumatic
or habitual and voluntary. In the latter case, congenital
deficiency of the superior peroneal retinaculum and a
shallow fibular groove may play a role. 4 In traumatic
chronic subluxation, there is little to be gained with
conservative management, and surgical management is
generally advocated. 4-10
Many surgical techniques have been described. Primary repair of the superior peroneal retinaculum4-6,11 is
feasible if the remaining retinaculum available to cover
the tendons is sufficient. When the superior peroneal
retinaculum is deficient, reconstructive procedures include groove deepening,8,10,12 bone block procedures,13
reinforcement of the superior peroneal retinaculum with
a tendon graft,7,8,14-16 peroneal tendons rerouting,17,18 or a
combination of these techniques. Recently, reconstruction of the superior peroneal retinaculum using anchors
has been described.19 We report our own technique for
such a procedure.
Preoperative Planning
Instability is assessed clinically. A comprehensive examination of the ankle and foot is required to exclude other
pathology, such as a lesion of the anterior talofibular
ligament. Recurrent or chronic dislocation of the peroneal tendons presents with instability and clicking of the
lateral aspect of the ankle, with the tendons subluxing
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Bulletin of the Hospital for Joint Diseases Volume 63, Numbers 3 & 4
2006
Figure 1 Exposure and sectioning of the common peroneal
tendon sheath.
Figure 2 The lateral aspect of the lateral malleolus with the
deficient superior peroneal retinaculum exposed by anterior retraction.
Figure 3 The lateral malleolus is roughened up with a periosteal
elevator.
Figure 4 The anchors in situ.
anteriorly.
peroneal tendons are identified by blunt dissection, and
protected. The lateral aspect of the lateral malleolus is
exposed (Fig. 2), and the “pouch” formed between the
bony surface of the lateral malleolus and the superior
peroneal retinaculum, where the tendons sublux, becomes
visible.
The bony surface of the lateral malleolus is roughened
up with a periosteal elevator to produce a bleeding surface
(Fig. 3), and three or four anchors are inserted along
the posterior border of the lower fibula (Fig. 4). After
manually testing that the anchors cannot be dislodged,
the superior peroneal retinaculum is reconstructed (Fig.
5), making sure that the pouch between the bony surface of the lateral malleolus and the superior peroneal
retinaculum is totally obliterated (Fig. 6). The ankle is
kept in eversion and slight dorsiflexion to assure that the
peroneal tendons are in the “worst possible position.” The
Surgical Procedure
The procedure is performed under general or spinal anaesthetic. The patient is placed supine on the operating
table with a sandbag under the buttock of the operative
side to internally rotate the affected leg. A tourniquet is
applied to the thigh, the leg exsanguinated, and the cuff
inflated to 250 mmHg.
A 5 cm longitudinal incision along the course of the
peroneal tendons is made starting posterior to the tip
of the lateral malleolus and progressing proximally,
staying well anterior to the sural nerve. The incision is
deepened to the peroneal tendon sheath, which is incised
longitudinally 3 mm posterior to the posterior border of
the fibula (Fig. 1). The superior peroneal retinaculum is
normally thin and deficient, especially anteriorly. The
Bulletin of the Hospital for Joint Diseases
Volume 63, Numbers 3 & 4
2006
115
Figure 5 The superior peroneal retinaculum is reconstructed.
Figure 6 Restoration of the integrity of the superior peroneal
retinaculum.
strength of the repair is tested moving the ankle through
the whole range of motion.
The wounds is closed in layers with 2-0 vicryl
(Ethicon, Edinburgh, UK) for the subcutaneous fat,
subcuticular undyed 3-0 vicryl (Ethicon, Edinburgh,
UK), and steristrips (3M, Loughborough, UK). Dressing swabs, dressing, and crepe bandage are applied. A
below knee walking synthetic cast is applied with the
ankle in neutral and slight eversion. Weightbearing is
allowed from the day after the operation, and the plaster
is removed four weeks after the procedure, after which
rehabilitation is started. Gradual return to activities and
to sport is allowed over the course of three to four months
postoperatively.
tion related to the use of biodegradable anchors has been
described, but in most instances this runs subclinically
and passes unnoticed.22,23 We have not experienced any
clinical complications related to the anchors, whether
metallic or bioabsorbable, using this technique.
Though seldom indicated given the rarity of patients presenting with such pathology, this procedure is
technically easy, with minimal disturbance of the local
anatomy, is safe and restores the normal relationship of
the peroneal tendons in their groove.
Discussion
2.
Acute dislocation of the peroneal tendons is often misdiagnosed as an ankle sprain and treated by early mobilization, which may increase the risk of chronic dislocation.
Surgical reconstruction for recurrent subluxation of the
peroneal tendons poses a challenge. Many procedures
have been described, but some are non-physiological
and have marked postoperative morbidity. For example,
bone block procedures may lead to fracture of the graft
or of the lateral malleolus, intra-articular placement of
the screws, and recurrence of the subluxation. 20
Intraoperative problems may include damage to the
sural nerve, which is usually between 7 and 14 mm posterior to the tip of the fibula. This risk can be minimized by
formal identification and protection of the nerve, which
can be retracted posteriorly with the short saphenous
vein at the beginning of the procedure.21 However, the
approach that we describe is safely anterior to the nerve
and it is not necessary to formally identify and protect
it.
Early postoperative problems may include hematoma
and wound infection. Inflammatory foreign-body reac-
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