Operative treatment of isolated epiphyseal fracture of the distal fibula: 1 case report and literature review.

Pediatric ankle injuries are common; ankle epiphyseal fractures are also common in children. But isolated distal epiphyseal fibular fractures of the distal fibula are clinically rare. We describe one unusual case of an adolescent with a completely displaced Salter-Harris type II distal fibular epiphyseal fracture. The attempt of closed reduction failed, and the patient required open reduction and internal fixation. The localized periosteum and the superior peroneal retinaculum were avulsed from the distal fibular metaphysis, with the peroneal tendons underneath exposed but no obvious subluxation. To the best of our knowledge, this combination of injuries has not been previously reported.

Comparison of Clinical Efficacy between Arthroscopic and Open Surgery for Ogden Type 1-2 Peroneal Tendon Dislocation.

OBJECTIVE: While the incidence of peroneal tendon dislocation (PTD) is relatively low, it is frequently underdiagnosed in clinical practice, and the misdiagnosis or improper treatment of this condition may lead to a decline in patients' quality of life. Currently, the surgical treatment options for PTD mainly include open and arthroscopic surgery. However, in order to evaluate the advantages and disadvantages of these two surgical approaches, further comparative research is needed. Therefore, the aim of this study is to investigate the early clinical outcomes of arthroscopic and open surgery in the treatment of Ogden type 1-2 PTD. METHODS: We conducted a comprehensive analysis of 46 patients diagnosed with PTD who underwent surgery at our institution between January 2017 and January 2023. The patients were divided into two groups: the open surgery group, consisting of 26 cases, and the arthroscopic surgery group, consisting of 20 cases. To compare the effectiveness of the surgical approach, we evaluated several parameters, including the integrity of the superior peroneal retinaculum on MRI images, functional scores, pain interference scores, and ankle eversion muscle strength. These assessments are conducted respectively before the surgery, 1 month after the surgery, 3 months after the surgery, and at the final follow-up for each group of patients (at least 6 months post-surgery). Demographics and intergroup comparisons of the two groups of data were analyzed by t-test or the Mann-Whitney U test. Intragroup comparisons of the two groups of data were analyzed by one-way analysis of variance (ANOVA) or the Kruskal-Wallis test, followed by post hoc multiple comparisons. RESULTS: In the intragroup comparisons, both the arthroscopic surgery and the open surgery group demonstrated significant improvement in functional scores, pain interference scores, muscle strength, and MRI findings at the final follow-up postoperatively (p < 0.01). However, the open surgery group exhibited significant improvements in these outcomes at the final follow-up, while the arthroscopic surgery group showed significant improvement at 3 months postoperatively. In intergroup comparisons, the arthroscopic surgery group outperformed the open surgery group in functional scores, pain interference scores, and muscle strength 3 months after the surgery, with statistically significant differences (p < 0.01). CONCLUSION: Arthroscopic surgery offers advantages in early clinical outcomes, such as pain relief, function, and muscle strength improvement. However, over time, both approaches provide similar results regarding effectiveness.

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.

Superior peroneal retinaculum reattachment for an atraumatic peroneus brevis tendon subluxation: a case report.

BACKGROUND: Peroneal tendon subluxation is a rare pathology, generally associated with sport-induced trauma, that occurs due to the rupture of the superior peroneal retinaculum. The diagnosis is mainly clinical, but the use of imaging techniques, such as dynamic ultrasound and magnetic resonance imaging, may contribute to its clarification. Treatment may be conservative or surgical, although there is no consensus on the most appropriate technique to be employed. We report a case of subluxation of the peroneus brevis tendon, with no apparent traumatic cause, in which there was a need for a surgical approach after the failure of conservative treatment. CASE PRESENTATION: A 25-year-old White woman presented pain and locking of the lateral side of the left foot 2 years earlier, with no history of trauma. The patient felt pain upon palpation and presented snapping during flexion-extension of the left ankle. On dynamic ultrasonography, an anterior subluxation of the peroneus brevis tendon occurred when the ankle was in dorsiflexion, suggesting superior peroneal retinaculum injury. Surgical correction was recommended after 2 months of conservative treatment with no improvement. The chosen surgical technique was isolated reattachment of the superior peroneal retinaculum, which proved successful. CONCLUSIONS: Peroneal tendon subluxation has no established preferred surgical technique. This case demonstrates superior peroneal retinaculum repair as an efficient surgical approach for this condition. Furthermore, the atraumatic mechanism of injury in this case, along with the unknown true incidence of peroneal tendon subluxation, highlights the need to consider this pathology in cases of ankle injuries.

Peroneal Stabilization Via Tightening of the Peroneal Tendon Sheath.

Peroneal subluxation is a rare but debilitating pathology that can be the result of a superior peroneal retinaculum tear or intrasheath laxity. On clinical examination of both cases, the pathology is observed when the ankle is circumducted in eversion and dorsiflexion. With a superior peroneal retinaculum tear, the tendons dislocate from the peroneal groove, whereas with intrasheath laxity the tendons remain in the groove. In the present case series, peroneal stabilization was performed for both superior peroneal retinaculum tear and intrasheath laxity. With our technique, the fibro-osseous connections of the peroneal tendon sheath are detached from the distal one third of the fibula. Drill holes are made through the fibula for suture to be passed through and the peroneal tendon sheath is reattached to the fibula through horizontal mattress sutures via pants over vest technique to restore tension to the sheath. A total of 5 patients underwent peroneal stabilization, 100% (5/5) of which had preoperative pain with palpation along the peroneal tendons and a palpable click with range of motion of the ankle joint. Postoperatively, 100% (5/5) of the patients were fully weight-bearing, compared to 60% (3/5) preoperatively. No patients had residual subluxation of the peroneal tendons postoperatively or a need for revisional surgery. Residual peroneal tendonitis was present in 20% (1/5) of patients and sural neuritis occurred in 20% (1/5) of patients. The peroneal tendons are physiologically tightened within the peroneal tendon sheath to mitigate the pathologic subluxation, without sacrificing tendons for transfer or using allograft material.Clinical Level of Evidence: Therapeutic, Case Series, Level 4.

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.

Concomitant Lateral Ankle and Peroneal Tendon Instability Treated With Simultaneous Arthroscopic Broström and Tendoscopic Superior Peroneal Retinaculum Repair: A Case Report.

Chronic lateral ankle instability is a prevalent condition, and it is commonly associated with other foot and ankle injuries. Among the associated injuries, peroneal tendon pathologies and anterolateral ankle impingement are frequently encountered. In this report, a case of concomitant chronic lateral ankle instability and dislocation of the peroneal tendons is described. While this combination of injuries is not uncommon, the method of treatment entailed arthroscopic repair of the anterior talofibular ligament and endoscopic repair of the superior peroneal retinaculum, procedures that eliminated the anterior drawer instability that had been present, and the patient remained symptom free after 24 months of follow-up.

The posterior fibulotalocalcaneal ligament complex: a forgotten ligament.

PURPOSE: The purpose of the present anatomical study was to define the exact morphology of the posterior fibulotalocalcaneal ligament complex (PFTCLC), both for a better orientation and understanding of the anatomy, especially during hindfoot endoscopy. METHODS: Twenty-three fresh frozen specimens were dissected in order to clarify the morphology of the PFTCLC. RESULTS: In all specimens, the ligament originated from the posteromedial border of the lateral malleolus between the posterior tibiofibular ligament (superior border) and the calcaneofibular ligament (CFL), (inferior border). This origin functions as the floor for the peroneal tendon sheath. The origin of the PFTCLC can be subdivided into two parts, a superior and inferior part. The superior part forms an aponeurosis with the superior peroneal retinaculum and the lateral septum of the Achilles tendon. From this structure, two independent laminae can be identified. The inferior part of the origin has no role in the aponeurosis and ligamentous fibres run obliquely to insert in the lateral surface of the calcaneus, in the same orientation as the CFL, but slightly more posterior, which was a consistent finding in all examined specimens. The PFTCLC is maximally tensed with ankle dorsiflexion and is located within the fascia of the deep posterior compartment of the leg. CONCLUSIONS: The PFTCLC is part of the normal anatomy of the hindfoot and therefore should be routinely recognized and partly released to achieve access to the posterior ankle anatomical pathology, relevant for hindfoot endoscopy. The origin of the ligament complex forms the floor for the peroneal tendon sheath. The superior part of the origin plays a role in the formation of an aponeurosis with the superior peroneal retinaculum and the lateral septum of the Achilles tendon.

Peroneal Tendon Subluxation and Dislocation in Calcaneus Fractures.

The present study investigated the relationship between type of calcaneal fractures and subluxation or dislocation of peroneal tendon. Also, we investigated clinical outcomes of patients with both calcaneal fractures and dislocations or subluxations of peroneal tendons in early surgical treatments (at the time of surgery for calcaneal fractures) and delayed surgical treatment (at the time of surgery for calcaneal plate removal) for dislocations or subluxations of peroneal tendons. We included 151 patients with calcaneal fractures who were followed for ≥2 years after surgery. Among them, 21 cases (13.9%) required reduction for peroneal tendon subluxation or dislocation. Reductions of peroneal tendons were performed at the time of surgery for calcaneal fractures in 11 cases, whereas the other 10 cases were performed during surgery for calcaneal implant removal. As classified by Essex-Lopresti, 94 cases (62.3%) were joint depression type and 17 (18.1%) were accompanied by dislocations or subluxations of peroneal tendons, whereas 57 (37.7%) were tongue type and 4 (7.0%) were accompanied by dislocations or subluxations of peroneal tendons. As classified by the Sanders system, 96 cases (63.6%) were Sanders A fracture lines, and 18 (18.8%) were accompanied by dislocations or subluxations of peroneal tendons. In 55 cases (36.4%) without Sanders A fracture lines, 3 (5.5%) were accompanied by dislocations or subluxations of peroneal tendons. In conclusion, calcaneal fractures with peroneal tendon dislocations are more common in joint depression type and Sander A type. Also, after a ≥2-year follow-up period, there were no significant differences in visual analog scale or foot and ankle outcome score whether reduction of peroneal tendons was done with reduction of fracture or removal of implant of calcaneus.

Management of Neglected Peroneal Tendon Dislocation of Iatrogenic Etiology: A Case Report.

Introduction: Neglected peroneal tendon dislocation with iatrogenic etiology has been rarely reported in the literature and its management has not been fully understood to date. Case Report: We present a case of a 25-year-old male who presented with pain over the posterolateral aspect of his left ankle which was diagnosed to be a case of neglected peroneal tendon dislocation of iatrogenic etiology. Peroneal groove deepening with superior retinaculum repair was done in the patient along with loose body removal and osteophyte excision. Subsequent fibrosis augmented with the deepening of the groove maintained peroneal tendon position in the retromalleolar groove. On post-operative follow-up, the patient was completely satisfied with relief of pain and no complications. He also regained full range of motion and could walk without support. Conclusion: Surgical intervention of fibular groove deepening with superior peroneal retinaculum reconstruction results in an excellent outcome for neglected peroneal tendon dislocation.

Can We Release All Calcaneal Attachments of the Superior Peroneal Retinaculum During Extensile Lateral Approach to the Calcaneus?

During extensile lateral approach to the calcaneus, in order to see all fractured fragments and subtalar joint, all soft tissues including insertion site of superior peroneal retinaculum (SPR) on the calcaneus should be released. The aim of this study was to evaluate the probability of peroneal tendon dislocation by releasing all soft tissues attached to the calcaneus. In 10 fresh cadavers, after standard extensile lateral approach to the calcaneus in right side, all soft tissues attached to the lateral wall of the calcaneus were excised. In the left side of each cadaver, all soft tissues inserted to the superior border of calcaneal tuberosity in addition to the lateral wall of the calcaneus were cut out. Probable anterior dislocation of peroneal tendons in the retromalleolar groove was assessed by placing a clamp into the peroneal tendon sheath from distal to proximal and advancing it to the retromalleolar groove. Also by careful dissection, any instability of peroneal tendons was visualized. Not any anterior dislocation of peroneal tendons to the lateral malleolus tip was seen in any stage of the procedure. Insertions of the SPR to the fascia of the deep posterior compartment of the leg and the Achilles tendon sheath are the main soft tissue stabilizer of the peroneal tendons in the retromalleolar groove. So resection of the insertion site of the SPR to the calcaneus might not result in the peroneal tendon instabilities.

New aspect of morphometric study of the superior peroneal retinaculum: pertinent data for surgical repair and reconstruction.

BACKGROUND: This study was conducted to investigate characteristics, attachments and morphometric parameters of the superior peroneal retinaculum (SPR). MATERIALS AND METHODS: Morphology and morphometric details including width, length, thickness and angle of alignment of SPR in 109 embalmed cadaveric legs were investigated. The occurrence of peroneal tendon tear was also noted. RESULTS: Most of SPR originated from the fibrocartilaginous ridge of the lateral malleolus. The SPR might be a single band or split into proximal and distal bands inserted on the posterior intermuscular septum and lateral wall of calcaneus, respectively. Based on the characteristics and insertion patterns, the SPR could be divided into 3 types: type I (double band with subtype Ia and Ib), type II (single band) and type III (single band) with the prevalence of 56.88% (12.84%, 44.04%), 1.83%, and 41.28%, respectively. The average coordinate (X, Y axis) of the midpoint of width at origin measured from the tip of fibula in all types was 7.26±3.15 and 10.45±4.52 mm. The average coordinate of the midpoint at insertion on the posterior intermuscular septum was 24.06±4.94 and 13.35±5.18, and those inserted on the lateral wall of calcaneus was 21.45±7.88 and 13.59±6.73 mm. Prevalence of peroneus brevis (PB) tendon tear was 12.84% (14 cases) and was associated with SPR type Ib with statistical significance. CONCLUSIONS: Precise information of the characteristics, morphometric data and coordinates of attachment sites of SPR are essential for surgical procedures and reconstruction.

Concomitant Traumatic Peroneal Tendon Dislocation and Medial Malleolus Fracture: A Case Report.

Peroneal tendon dislocation in association with medial malleolus fracture is a very rare traumatic injury to the ankle. A 19-year old male patient was referred after injury sustained in a motorcycle accident with car, with concomitant traumatic peroneal tendon dislocation and medial malleolus fracture. The possible mechanism of this unusual injury could have been sudden external rotation force to the pronated foot in full dorsiflexed position of the ankle. Diagnosis of peroneal tendon subluxation or dislocation should be carefully evaluated in patients with single medial malleolus fracture.

Intrasheath Instability of the Peroneal Tendons: Dynamic Ultrasound Imaging.

Peroneal intrasheath instability is a painful snapping condition of the lateral ankle. It consists of a transient retromalleolar subluxation of the peroneal tendons without disruption of the superior peroneal retinaculum or evidence of a previous definite trauma. In type A intrasheath instability, the peroneus longus and brevis tendons are intact, and there is an intertendinous intrasheath switch. In type B intrasheath instability, the peroneus brevis tendon has a longitudinal split tear through which the peroneus longus subluxates. Both types can be missed on a physical examination because there is no displacement of the peroneal tendons over the lateral malleolus. Dynamic ultrasound is the imaging modality of choice for evaluating retromalleolar subluxation of the peroneal tendons. This review article aims to provide an overview of the anatomic basis for peroneal intrasheath instability and provide physicians with guidelines for its ultrasound assessment.

Tendoscopic Treatment of Peroneal Intrasheath Subluxation: A New Subgroup With Superior Peroneal Retinaculum Injury.

BACKGROUND: Snapping peroneal tendons is a rare cause of lateral ankle pain. Two subgroups have been described: chronic subluxation with superior peroneal retinaculum (SPR) injury and intrasheath subluxation with SPR intact. The aim of the study was to report the tendoscopic findings and results in patients affected by snapping peroneal tendons without evident dislocation. METHODS: Between 2010 and 2015, a total of 18 patients with a retromalleolar "click" sensation and no clinical signs of peroneal tendon dislocation underwent tendoscopy. Mean age was 29 years (range, 18-47). Mean follow-up was 45 months (range, 18-72). RESULTS: Tendoscopic examination revealed an intact SPR in 12 patients. Of these 12, a space-occupying lesion was present in 7, a superficial tear of peroneus brevis in 4, and a shallow fibular groove in 7. An SPR injury without peroneal tendon dislocation was observed in the remaining 6 patients. All these 6 patients presented a shallow fibular groove. Although the SPR was injured, they had been diagnosed as intrasheath subluxation. Patients with intrasheath subluxation and intact SPR underwent debridement of a space-occupying lesion in 11 cases and fibular groove deepening in 5 cases. Patients with intrasheath subluxation and SPR injury underwent fibular groove deepening without addressing the SPR. At follow-up, the mean American Orthopaedic Foot & Ankle Society score increased from 76 (range, 69-85) preoperatively to 97 (range, 84-100). No recurrence or major complications were reported. Conclusion Intrasheath subluxation of peroneal tendons was successfully treated tendoscopically. A new subgroup of intrasheath subluxation with SPR injury but no clinically evident peroneal tendon dislocation is reported. LEVEL OF EVIDENCE: Level IV, case series.

The lateral malleolar bony fleck classified by size and pathoanatomy: The IOFAS classification.

BACKGROUND: This study analyzes position of the peroneal tendons and status of the superior peroneal retinaculum (SPR) whenever a lateral malleolar bony flake fracture occurs. METHODS: Twenty-four patients had a lateral malleolar bony fleck on anteroposterior ankle radiographs, either in isolation or associated with other hindfoot injuries. We studied size of the bony flecks, presence or absence of peroneal tendon dislocation and pathoanatomy on CT scans. RESULTS: In 11 patients, a small bony fleck lies within the superior peroneal retinaculum and contiguous periosteum, which are stripped off the lateral fibula (Class II lesions). Tendons dislocate into the subperiosteal pouch thus formed, resembling Class I lesions without associated bony avulsion. Treatment for Class II is same as for Class I injuries. In 8 patients with a big bony fleck, tendons dislocate into the fracture site and SPR is intact (Class III lesions). In Class IV lesions, observed in 5 patients with 2-part calcaneal fracture/dislocation, SPR remains intact and peroneal tendons are not dislocated. The invariably large fleck results from the displacing lateral calcaneal fragment abutting against the fibula, whereas the dislocating tendons cause the bony avulsions in Classes II and III. CONCLUSIONS: Due to pathoanatomical differences, surgical approach and natural history of neglected lesions differ depending on size of the bony fleck. The SPR must not be incised in case of big Class III flecks.

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.

Eckert and Davis Grade 3 Superior Peroneal Retinaculum Injury: Treated by Endoscopic Peroneal Retinaculum Reconstruction and Complicated by Malposition of the Suture Anchors.

INTRODUCTION: Eckert and Davis grade 3 superior peroneal retinaculum injury is rare and the optimal treatment is not yet determined. CASE REPORT: A 57 year-old lady sprained her left ankle resulting in grade 3 injury of the superior peroneal retinaculum and was treated by endoscopic retinaculum reconstruction. The fracture healed and the peroneal tendons were stabilized. However, it was complicated by protusion of the suture anchors into the posterolateral ankle gutter. The implants were successfully removed endoscopically. CONCLUSION: Proper selection of the size and dimension of the suture anchor and preoperative planning with computed tomogram is important for usage of suture anchors in the lateral malleolus.