113 BulletinoftheHospitalforJointDiseases Volume63,Numbers3&4 2006

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 pro-cedure is safe and effective in managing instability.

The peroneal tendons share a common tendonsheathproximaltothedistaltipofthefibulawiththe peroneus brevis medial and anterior to the

peroneus longus.Moredistally,eachtendonlies in itsownsheath.Thecommonsheathiscontainedwithinasulcus,thefibulargroove,ontheposterolateralaspectofthefibula,preventingsubluxation.Thegrooveis5to10mmwideandupto3mmdeep.1Theprimaryrestrainttotendonsubluxationisthesuperiorperonealretinaculum.Thisfibrousbandoriginatesontheposterolateralaspectof thefibulaandinsertsontothelateralsurfaceof thecalcaneus.Itis10to20mmwide,isreinforcedsuper-ficiallyby transverse fibers, andcourses in apostero-inferiordirection,althoughvariantsinwidth,thickness,andinsertionalpatternsarenotuncommon.1Theinferiorperonealretinaculumisattachedtotheperonealtrochleaandcalcaneusaboveandbelowtheperonealtendons. Acutetraumaticsubluxationoftheperonealtendons

isuncommon.2Acute injuries to the superiorperonealretinaculumcanbeinitiallymanagedconservativelywithimmobilizationinanon-weightbearingcast,2whichhasareportedsuccessrateofapproximately50%.2,3

Inchronicsubluxation,patientsoftenrevealahistoryofpreviousankleinjurythat,insomecases,mayhavebeenmisdiagnosedasasprain.Anunstableankle thatgiveswayorthatisassociatedwithapoppingorsnap-pingsensation isanothercommoncomplaint.Chronicsubluxationof theperoneal tendonsmaybe traumaticorhabitualandvoluntary.Inthelattercase,congenitaldeficiency of the superior peroneal retinaculum and ashallow fibular groove may play a role.4 In traumaticchronic subluxation, there is little to be gained withconservativemanagement,andsurgicalmanagementisgenerallyadvocated.4-10 Manysurgical techniqueshavebeendescribed.Pri-maryrepairofthesuperiorperonealretinaculum4-6,11isfeasibleiftheremainingretinaculumavailabletocoverthe tendons is sufficient.When the superior peronealretinaculum is deficient, reconstructive procedures in-cludegroovedeepening,8,10,12 boneblockprocedures,13reinforcementofthesuperiorperonealretinaculumwithatendongraft,7,8,14-16peronealtendonsrerouting,17,18oracombinationofthesetechniques.Recently,reconstruc-tionofthesuperiorperonealretinaculumusinganchorshasbeendescribed.19Wereportourowntechniqueforsuchaprocedure.

Preoperative PlanningInstabilityisassessedclinically.Acomprehensiveexami-nationoftheankleandfootisrequiredtoexcludeotherpathology, such as a lesion of the anterior talofibularligament.Recurrentorchronicdislocationofthepero-nealtendonspresentswithinstabilityandclickingofthelateralaspectof theankle,withthetendonssubluxing

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)

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.

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anteriorly.

Surgical ProcedureTheprocedureisperformedundergeneralorspinalan-aesthetic.Thepatientisplacedsupineontheoperatingtablewithasandbagunderthebuttockoftheoperativesidetointernallyrotatetheaffectedleg.Atourniquetisappliedtothethigh,thelegexsanguinated,andthecuffinflatedto250mmHg. A5cmlongitudinalincisionalongthecourseoftheperoneal tendons is made starting posterior to the tipof the lateral malleolus and progressing proximally,stayingwellanteriortothesuralnerve.Theincisionisdeepenedtotheperonealtendonsheath,whichisincisedlongitudinally3mmposteriortotheposteriorborderofthefibula(Fig.1).Thesuperiorperonealretinaculumisnormally thin anddeficient, especially anteriorly.The

peronealtendonsareidentifiedbybluntdissection,andprotected.Thelateralaspectofthelateralmalleolusisexposed(Fig.2),andthe“pouch”formedbetweenthebony surface of the lateral malleolus and the superiorperonealretinaculum,wherethetendonssublux,becomesvisible. Thebonysurfaceofthelateralmalleolusisroughenedupwithaperiostealelevatortoproduceableedingsurface(Fig. 3), and three or four anchors are inserted alongtheposteriorborderof the lower fibula (Fig.4).Aftermanuallytestingthattheanchorscannotbedislodged,thesuperiorperonealretinaculumisreconstructed(Fig.5),making sure that thepouchbetween thebony sur-faceof the lateralmalleolusand thesuperiorperonealretinaculumistotallyobliterated(Fig.6).Theankleiskeptineversionandslightdorsiflexiontoassurethattheperonealtendonsareinthe“worstpossibleposition.”The

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 re-traction.

Figure 3 The lateral malleolus is roughened up with a periosteal elevator.

Figure 4 The anchors in situ.

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strengthoftherepairistestedmovingtheanklethroughthewholerangeofmotion. 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),andsteristrips (3M,Loughborough,UK).Dress-ingswabs,dressing,andcrepebandageareapplied.Abelow knee walking synthetic cast is applied with theankle in neutral and slight eversion.Weightbearing isallowedfromthedayaftertheoperation,andtheplasterisremovedfourweeksaftertheprocedure,afterwhichrehabilitationisstarted.Gradualreturntoactivitiesandtosportisallowedoverthecourseofthreetofourmonthspostoperatively.

DiscussionAcutedislocationoftheperonealtendonsisoftenmisdi-agnosedasananklesprainandtreatedbyearlymobiliza-tion,whichmayincreasetheriskofchronicdislocation.Surgicalreconstructionforrecurrentsubluxationoftheperoneal tendons poses a challenge. Many procedureshave been described, but some are non-physiologicalandhavemarkedpostoperativemorbidity.Forexample,boneblockproceduresmayleadtofractureofthegraftorofthelateralmalleolus,intra-articularplacementofthescrews,andrecurrenceofthesubluxation.20

Intraoperativeproblemsmayincludedamage to thesuralnerve,whichisusuallybetween7and14mmposte-riortothetipofthefibula.Thisriskcanbeminimizedbyformalidentificationandprotectionofthenerve,whichcan be retracted posteriorly with the short saphenousveinat thebeginningof theprocedure.21However, theapproachthatwedescribeissafelyanteriortothenerveanditisnotnecessarytoformallyidentifyandprotectit. Earlypostoperativeproblemsmayincludehematomaandwoundinfection.Inflammatoryforeign-bodyreac-

tionrelatedtotheuseofbiodegradableanchorshasbeendescribed,butinmostinstancesthisrunssubclinicallyandpassesunnoticed.22,23Wehavenotexperiencedanyclinical complications related to the anchors, whethermetallicorbioabsorbable,usingthistechnique. Though seldom indicated given the rarity of pa-tientspresentingwithsuchpathology,thisprocedureistechnicallyeasy,withminimaldisturbanceofthelocalanatomy,issafeandrestoresthenormalrelationshipoftheperonealtendonsintheirgroove.

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Figure 5 The superior peroneal retinaculum is reconstructed. Figure 6 Restoration of the integrity of the superior peronealretinaculum.

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