ARTICLE IN PRESS

TIPS, QUIPS, AND PEARLS

“Tips, Quips, and Pearls” is a special section in The Journal of Foot & Ankle Surgery which is devoted to the sharing ofideas to make the practice of foot and ankle surgery easier. We invite our readers to share ideas with us in the form of specialtips regarding diagnostic or surgical procedures, new devices or modifications of devices for making a surgical procedurea little bit easier, or virtually any other “pearl” that the reader believes will assist the foot and ankle surgeon in providingbetter care. Please address your tips to: D. Scot Malay, DPM, MSCE, FACFAS, Editor, The Journal of Foot & AnkleSurgery, PO Box 590595, San Francisco, CA 94159-0595; E-mail: editorjfas@gmail.com

A Simplified Technique for Repair ofRecurrent Peroneal Tendon Subluxation

Simon E. Smith, BPod, MPod,1 Craig A. Camasta, DPM,2 and Andrea D. Cass, DPM3

1Podiatrist, The Essendon Foot Clinic, Essendon, VIC, Australia.2Fellow, American College of Foot and Ankle Surgeons; Faculty, ThePodiatry Institute, Decatur, GA.33rd-Year Resident, Dekalb Medical Centre, Decatur, GA.

Peroneal tendon subluxation or dislocation denotes intermittent or chronic anterior displacement of theperoneus longus and brevis tendons out of their fibro-osseous tunnel at the distal and posterior aspectof the fibula. Numerous surgical techniques have been described to address peroneal tendon subluxa-tion, including isolated or combined soft tissue and osseous reconstructive procedures. The authorspresent an efficient and simplified approach for addressing this pathology using multiple, nonabsorbableretention sutures without the need for extensive dissection or osteotomy. (The Journal of Foot & AnkleSurgery xx(x):xxx, 2009)

Key Words: dislocation, peroneal tendon, peroneus brevis, peroneus longus, subluxation

Peroneal tendon subluxation and dislocation invariablyoccurs secondary to disruption or elevation of the supe-rior peroneal retinaculum (SPR) from its insertion alongthe posterolateral margin of the fibula, with or withoutdisplacement of the associated fibro-cartilaginous ridgeor cortical fibular fragment (1). Anatomical variants havebeen implicated in peroneal subluxation and dislocation,including the presence of a shallow or convex fibularperoneal sulcus and anomalous distal extension of theperoneus brevis muscle into the fibro-osseous tunnel thatsurrounds the peroneal tendons (1, 2). Interestingly, thispathological tendon malposition is commonly associated

Address correspondence to: Simon E. Smith, BPod, MPod, The EssendonFoot Clinic, Essendon, VIC, Australia 3040. E-mail: simonsmithpod@optusnet.com.au

Financial Disclosure: None reported.Conflict of Interest: None reported.© 2009 Published by Elsevier Inc. on behalf of the American College

of Foot and Ankle Surgeons

1067-2516/09/xxx-0001$36.00/0doi:10.1053/j.jfas.2008.10.006

with lateral ankle instability (3–5), and is reported tocommonly occur in association with athletic activities(6 –9). Peroneal tendon subluxation injury typically oc-curs in relation to forceful contraction of the respectivemusculature while the foot is dorsiflexed, with or withoutan inverted position of the foot and ankle (1, 10). Surgi-cal intervention is often used to treat symptomaticchronic peroneal tendon subluxation and/or dislocation.In this article, the authors describe a simple approach forSPR repair and indirect reduction of subluxated peronealtendons into the peroneal groove on the posterior aspectof the fibula.

Operative Technique

The patient is positioned in the lateral decubitus or supineposition with a bolster underlying the ipsilateral hip tofacilitate internal rotation of the respective extremity andexposure. A 6- to 8-cm longitudinal incision is made over

the posterolateral aspect of the distal fibular, extending to

VOLUME XX, NUMBER X, MONTH 2009 1

ARTICLE IN PRESS

the fibular malleolus (Figure 1). Anatomical dissection andhemostasis are used to expose the deep fascia and peronealretinaculum (Figure 2). Exposure is carried out to the pointthat the subluxated peroneal tendons are identified withintheir distended tunnel or sheath. Next, the peroneal tendonsare manipulated back into their correct anatomical positionposterior to the fibula, with the use of a blunt instrumentsuch as an unloaded scalpel handle or the hinge (proximal)portion of an Adson forceps (Figure 3). The tendons aremaintained in this position with the blunt instrument whilea moderate- to large-caliber nonabsorbable suture, such as a2–0 braided nylon, is used to reef the SPR and the sheath.The technique involves placing multiple interrupted over-and-over sutures along the distal course of the SPR/peronealtendon sheath, at the level of the posterolateral margin of the

FIGURE 1 Incision placement for the approach for the peronealretinacular repair (black solid line). A Brostrom-Gould lateral ankleligament repair was performed concomitantly in this case.

FIGURE 2 Dissection is carried down to expose the superior per-oneal retinaculum and peroneal tendon sheath.

fibular. The aim is to reapproximate and anchor the SPR and

2 THE JOURNAL OF FOOT & ANKLE SURGERY

sheath insertion to the periosteum along the posterolateralmargin of the fibula. The size of the “suture bite,” or theamount of soft tissue reefing, that is required depends on thedegree of distension of the respective retinaculum andsheath. Care must be taken to avoid overly tightening thefibro-osseous tunnel, thereby stenosing the peroneal ten-dons.

With the foot maintained at 90 degrees to the leg and theperoneal tendons situated posterior to the fibula, the over-and-over sutures are thrown from posterior and lateral to

FIGURE 3 The peroneal tendons are manipulated back into theircorrect anatomical position posterior to the fibula, in this case usingthe blunt end of the handle of an Adson-Brown forceps (any bluntinstrument can be used for this maneuver).

FIGURE 4 The peroneal tendons are maintained behind the fibu-lar. The over-and-over suture technique begins lateral and posterior,biting the distended peroneal retinaculum and sheath and progress-ing anterior, ensuring the needle passes through both periosteumand the fibrocartilaginous postero-lateral lip of the fibular-peronealtunnel. In this case, a 2–0 braided nylon suture was used.

anterior, purchasing the distended SPR and sheath, while

ARTICLE IN PRESS

making sure that the needle passes through both periosteumand the fibrocartilaginous posterolateral lip of the fibular-peroneal tunnel (Figure 4). The needle is subsequently re-routed back through the SPR and sheath while progressinganteriorly, ensuring that the needle passes once againthrough both periosteum and the fibrocartilaginous postero-lateral lip of the fibular-peroneal tunnel. Approximately 5 to6 interrupted over-and-over sutures are placed and left un-tied (Figure 5) until all have been positioned and the finalposition of the peroneal tendons has been assessed. Allindependent suture throws are then tied with sufficient ten-sion, progressing sequentially from superior to inferior toensure maintenance of the reduction (Figure 6). The ankle isthen plantarflexed and dorsiflexed and the repair is criticallyinspected for stability and uninterrupted gliding of the per-

FIGURE 5 Approximately 5 to 6 over-and-over sutures are per-formed and left untied until all have been placed and the finalperoneal tendon position has been assessed.

FIGURE 6 All independent suture throws are then tied down pro-gressively, under sufficient tension, from superior to inferior to en-sure maintenance of reduction.

oneal tendons within the sheath (Figure 7).

The wound is then irrigated and is closed in layers, afterwhich the foot and ankle are dressed in a sterile Jonescompression bandage with a posterior splint holding theankle and foot in a 90-degree relationship. Postoperatively,the patient is kept non–weight bearing for 3 weeks, afterwhich time the patient is allowed to ambulate with partialweight bearing in an immobilizing boot, progressively bear-ing increased weight on the operated side to the point of fullweight bearing over an approximately 3-week period ofadditional time. At 6 weeks post operation, the patienttypically returns to lace-up footgear with a compressiongarment, but is restricted to flat surfaces and allowed exer-cise in the form of stationary bike, elliptical trainer, or levelground walking. No activity involving medial to lateral orpivoting motion is recommended until approximately 12weeks following the operation, when unrestricted activity is

FIGURE 7 The ankle is then plantarflexed (A) and dorsiflexed (B)and the repair is critically inspected for stability and adequacy ofrepair.

usually capable of being sustained.

VOLUME XX, NUMBER X, MONTH 2009 3

ARTICLE IN PRESS

Discussion

The senior author (C.A.C.) has performed the techniquedescribed in this report in 16 patients over an approximately12-year period of time, and has had no cases of recurrentperoneal subluxation or dislocation. Based on this experience,a number of important caveats seem to be associated withsuccess. First, this procedure is a “no-look” technique that ispredicated on the absence of intrinsic peroneal tendon pathol-ogy. That is to say, there is no evidence of intratendinous tearthat requires intrasheath dissection, and the SPR and tendonsheath must remain intact. Therefore, preoperative imaging inthe form of ultrasound or magnetic resonance image (MRI)scans, in conjunction with a thorough clinical examination, isrequired for the surgeon to be reasonably assured that thetendon/s are intact. Caution is recommended, however, inregard to depending totally on MRI scans to ascertain the statusof the tendons within the peroneal sheath (11, 12), and sur-geons are encouraged to carefully assess the patient clinically.If there is doubt as to the integrity of the intrasheath structures,then surgical inspection should be considered. In cases of acuteperoneal tendon subluxation or dislocation with overt ruptureof the SPR and sheath, and/or avulsion of a portion of thefibular cortical fragment, direct peroneal tendon realignmentand anatomic reconstruction must be considered. Furthermore,in the presence of a convex fibular sulcus, an osseous proce-

dure to deepen the sulcus is recommended.

4 THE JOURNAL OF FOOT & ANKLE SURGERY

References

1. Eckert W, Davis E. Acute rupture of the peroneal retinaculum. J BoneJoint Surg 58A:670–673, 1976.

2. Edwards M. The relations of the peroneal tendons to the fibula,calcaneus, and cuboideum. Am J Anat 42:213–252, 1927.

3. Geppert MJ, Sobel M, Bohne WHO. Lateral ankle instability as acause of superior peroneal retinacular laxity: an anatomic and biome-chanical study of cadaveric feet. Foot Ankle 14:330–334, 1993.

4. Marti R. Dislocation of the peroneal tendons. Am J Sports Med5:19–22, 1977.

5. McLennan JG. Treatment of acute and chronic luxations of the pero-neal tendons. Am J Sports Med 8:432–436, 1980.

6. Arrowsmith S, Fleming L, Allman F. Traumatic dislocations of theperoneal tendons. Am J Sports Med 11:142–146, 1983.

7. Das De S, Balasubramaniam P. A repair operation for recurrentdislocation of peroneal tendons. J Bone Joint Surg 67B:585–587,1985.

8. Mason RB, Henderson IJP. Traumatic peroneal tendon instability.Am J Sports Med 24:652–658, 1996.

9. McConkey JP, Favero KJ. Subluxation of the peroneal tendons withinthe peroneal sheath. A case report. Am J Sports Med 15:511–513,1987.

10. Ogawa BK, Thordarson DB. Current concepts review: peroneal tendonsubluxation and dislocation. Foot Ankle 28:1034–1040, 2007.

11. Kuwada GT. Surgical correlation of preoperative MRI findings oftrauma to tendons and ligaments of the foot and ankle. J Am PodiatrMed Assoc 98:370–373, 2008.

12. Lamm BM, Myers DT, Dombek M, Mendicino RW, Catanzariti AR,Saltrick K. Magnetic resonance imaging and surgical correlation of

peroneus brevis tears. J Foot Ankle Surg 43:30–36, 2004.