SAM A. L ABI B, MD / E ric Giza , MD e mo ryhe a lthc a re - - PowerPoint PPT Presentation

e mo ryhe a lthc a re .o rg / o rtho

PE RONE AL T E ARS & DISL OCAT IONS: OPE N RE PAIR F OR RE L IABL E RE SUL T S

SAM A. L ABI B, MD / E ric Giza , MD

DISCLOSURES FOR LABIB

• Re se a rc h/ F

e llo wshi p F unding : Arthre x, Ossur, L inva te c

• Co nsulta nt:

Arthre x, Me dsha pe , Stryke r

PERONEAL TENDONS

• Primary Function

– Eversion – Plantar flexion of the ankle and first ray

• Dynamic stabilizers of

the ankle and subtalar joints

Reed, Giza et al., Orthopaedic Knowledge Update: Sports Medicine 4, W.B. Kibler,

• Editor. 2009, American Academy of Orthopaedic Surgeons.

SUPERIOR PERONEAL RETINACULUM

• SPR: important for

peroneal stability

• 2 arms

– 1 to Achilles sheath – 1 to calcaneus (posterior and lateral to CFL)

Ogawa & Thordarson. Foot & Ankle International/Vol. 28, No. 9/September 2007

PE RONE ALT E NDONS + SPN

– Pe ro ne a l

T e ndo ns

– De la ye d

re c ruitme nt in Unsta b le a nkle s

– K

a rlsso n& Andre a sso n AJSM,1992

– SPN Se c tio n

Study: 15 % o f Sta tic sta b ilize rs

Ha tc h & L a b ib JOSA 2003

RETROMALLEOLAR SULCUS

• Retromalleolar Sulcus

– 5-10 mm wide – Cartilage rim = 2-4 mm

• Cadaver Study

– 82% had a concave sulcus – 7% had a convex sulcus – 11% had a flat sulcus

Edwards, E. Am. J. Anat. 42: 213 – 252, 1927.

PERONEAL INJURY

• Acute

– Sudden dorsiflexion with firing of peroneal tendons – back side of a mogul while skiing – Inversion with the foot in plantarflexion

• Chronic

– Repeated sprains, varus hindfoot lead to attenuation of SPR and synovitis

ZONE OF INJURY

• Zone 1 Injury: Fibular

groove area

– Often associated with P. Brevis

• Zone 2 Injury: cuboid

tunnel

– Often associated with P. Longus

Shawen & Anderson, Tech. Foot Ankle Surg. 3:118 – 125, 2004

HISTORY & EXAMINATION

• Lateral tenderness
• Popping at ankle when

everting or “driving to the hoop”

• Test with knee flexed,

the ankle is actively dorsiflexed and plantarflexed with resisted eversion

RADIOGRAPH

• “Fleck Sign”
• Pathognomonic for

peroneal tendon dislocation

• Fragment of bone is

lateral to the distal fibula metaphysis

MRI FINDINGS

• Axial T1 images

– Lateral/anterior displacement of brevis – Contour of the posterior fibula – Tear of brevis

• Mickey Mouse or Tie-Wing

fighter

MRI FINDINGS

• Axial T1 images

– Lateral/anterior displacement of brevis – Contour of the posterior fibula – Tear of brevis

• Mickey Mouse or Tie-Wing

fighter

MRI FINDINGS

• Co ro na l ima g e s

– L

a te ra l/ a nte rio r displa c e me nt o f b re vis

• MRI

ne e ds to b e c o rre la te d with c linic a l e xa m

– 56 pa tie nts with (+) MRI – 27/ 56 ha d (+) e xa m – 48% Po sitive Pre dic tive

Va lue

Giza E, Mak W et al. A clinical and radiological study of peroneal tendon pathology. Foot & ankle

• specialist. 2013 Dec;6(6):417-21.

PERONEAL TENDON DISLOCATION

• Peroneal Tendon

Subluxation

– Grade 1: SPR stripped from fibula – Grade 2: Fibrocartilage rim stripped – Grade 3: Bony avulsion

• Fleck sign

Eckert, W; Davis, E:. J.Bone Joint

• Surg. 58-A:670 – 673, 1976.

superior personal retinacular injury

fibula

Peroneal tendons

PERONEAL TENDON SUBLUXATION

PERONEAL TENDON SUBLUXATION

ACUTE DISLOCATION TREATMENT

• Immobilization can be

attempted

• Escalas found 28 (74%)
• f 38 patients had no

improvement after immobilization

• Operative treatment

recommended in most cases with 95% success*

Escalas et al, J. Bone Joint Surg. 62-A:451 – 453, 1980. *Eckert, W; Davis, E:. J.Bone Joint Surg. 58-A:670 – 673, 1976.

CASE EXAMPLE – ACUTE REPAIR

• 50 year old active male

skiier – forced dorsiflexion injury

• MRI and exam

demonstrate dislocation of brevis laterally

• SPR denuded from

lateral fibula

– Normal sulcus

ACUTE DISLOCATION

ACUTE REPAIR CONCEPTS

• 1. Re sto re pe rio ste um

a nd SPR to la te ra l fib ula b o ne

• 2. Re -e sta b lish

fib ro c a rtila g e no us rim

• 3. Se c ure ly re pa ir SPR

with e no ug h spa c e fo r te ndo n g liding

• Gro o ve de e pe ning

ra re ly ne c e ssa ry in a c ute re pa ir

Fibula Fibula

ACUTE REPAIR

• Anchors or Bone

Tunnels

• Double Row Repair
• Non Absorbable

Suture

ACUTE REPAIR

• Prepare lateral

fibula to create a good bed for repair

ACUTE REPAIR

• 1. Re sto re

pe rio ste um a nd SPR to la te ra l fib ula b o ne

• 2. Re -e sta b lish

fib ro c a rtila g e no us rim

ACUTE REPAIR

Anchors Placed Rim Restored

ACUTE REPAIR

Re pair with fr e e r e le vator in she ath to c r e ate e nough spac e for gliding

2 limbs of suture preseved

ACUTE REPAIR

Pe rioste um Se c ure d ba c k to fibula

ACUTE TENDON DISLOCATION REPAIR

ACUTE REPAIR

ACUTE ON CHRONIC OR CHRONIC TEARS

• Brevis or Longus

split tear from inversion or age related degeneration

– Less than 30% = remove

ACUTE ON CHRONIC OR CHRONIC TEARS

• Brevis or

Longus split tear from inversion or age related degeneration

–Approx 50% = repair

ACUTE ON CHRONIC OR CHRONIC TEARS

• Brevis or Longus

split tear from inversion or age related degeneration

– >75% = anastamosis of longus or brevis

• Allograft in

young patient

CHRONIC SUBLUXATION

• Add grove deepening
• U shaped saw cut in

grove (preserve periosteum)

• Tamp in place
• Repair attenuated SPR

with method above

• Good results reported

at 2 yrs

Shawen & Anderson, Tech. Foot Ankle Surg. 3:118 – 125, 2004

LOW LYING PERONEUS BREVIS

• Low lying peroneus

brevis muscle into the fibular groove can cause:

– Stretching of the SPR – Longitudinal splitting of the peroneus brevis tendon – Peroneal tenosynovitis

Sobel, M; Bohne, WHO; O Brien, SJ: Acta Orthop. Scand. 63:682 – 684, 1992. ’

PERONEAL TENDON DYSFUNCTION

• Anomalous Muscles

– Peroneus Quartus – Peroneocalcaneous Internus – Long accessory to FDL or QP – Tibiocalcaneous internus – Accesory soleus

Best, Giza, Sullivan, JBJS Am, 2005

Peroneus Quartus

Peroneal tendons

PERONEUS QUARTUS

• Ofte n a c a use o f

c o ntinue d pa in a fte r a nkle spra in

• I

nse rtio n o n la te ra l c a lc a ne us

• E

xc isio n with re pa ir o f a tte nua te d SPR pre fe rre d me tho d o f tre a tme nt

Best, Giza, Sullivan, JBJS Am, 2005

SUB- ACUT E F RACT URE OF OS PE RONE UM

Excision with direct repair using 2-0 Fiberwire performed

e mo ryhe a lthc a re .o rg / o rtho

• Ope rative T

e c hnique

• F

ib ula r g ro o ve de e pe ning

– 6c m c urviline a r inc isio n ma de o ve r pa th o f pe ro ne a l te ndo ns po ste rio r to fib ula – Re tina c ulum disse c te d a t po ste rio r a spe c t o f fib ula , 3mm sle e ve o f re tina c ulum a tta c he d to fib ula – F ib ro sse o us she a th o ste o to mize d o ff po ste rio r a spe c t o f fib ula a nd hing e d po ste rio rly – 3mm ro und b ur use d to de e pe n unde rlying fib ula , re mo ving 7- 9mm o f b o ne – F ib ro o se o us she a th impa c te d b a c k into de e pe ne d g ro o ve with b o ne impa c to r

• Re tina c ulum re pa ir

– Po uc h fo rme d b y b o ny surfa c e o f la te ra l ma lle o lus a nd supe rio r pe ro ne a l re tina c ulum e xpo se d – Drilling o f K irsc hne r-wire into la te ra l ma lle o lus to pro duc e b le e ding – 3-4 ho le s ma de a lo ng po ste rio r b o rde r o f lo we r fib ula – Sle e ve o f re ina c ulum a nd pe rio ste um a dva nc e d po ste rio r in ve st-o ve r-pa nts fa shio n – Do ub le -ro w re pa ir with 2.0 no n-a b so rb a b le suture s

–

5.5 mm c a the te r re mo ve d a fte r re tina c ulum wa s suture d

–

Ankle ma inta ine d in e ve rsio n a nd slig ht do rsifle xio n

e mo ryhe a lthc a re .o rg / o rtho

• Me a n AOF

AS sc o re impro ve d sig nific a ntly fro m 59.3 po ints pre o pe ra tive ly to 92.2 po ints a t the fina l fo llo w-up in g ro up A a nd fro m 58.5 po ints pre o pe ra tive ly to 91.3 po ints a t the fina l fo llo w-up in g ro up B.

• Me a n VAS sc o re a lso impro ve d sig nific a ntly fro m 5.0 po ints

pre o pe ra tive ly to 1.0 po ints a t the fina l fo llo w-up in g ro up A a nd fro m 4.9 po ints pre o pe ra tive ly to 1.2 po ints a t the fina l fo llo w-up in g ro up B.

• Impr
• ve me nts in AOF

AS and VAS sc or e s a t the fina l fo llo w-up

we re no t sig nific a ntly diffe re nt b e twe e n the 2 g ro ups. Me an

time to r e tur n to spor ts ac tivity was appr

• ximate ly 3 months in

both gr

• ups. Me a n to urniq ue t time in g ro up B wa s sig nific a ntly

sho rte r tha n tha t in g ro up A (42.2 vs 29.5 min).

• Conc lusion: Isolate d r

e pair > IR +Gr

• ove De e pe ning

RE F E RE NCE S

• Best, Giza, Sullivan, Peroneus Quartus. JBJS Am, 2005
• Cho J, Kim JY, Song DG, Lee WC. Comparison of outcome after

retinaculum repair with and without fibular groove deepening for recurrent dislocation of the peroneal tendons. Foot & ankle

• international. 2014 Jul;35(7):683-9.
• Escalas et al, J. Bone Joint Surg. 62-A:451 – 453, 1980.
• Eckert, W; Davis, E:. J.Bone Joint Surg. 58-A:670 – 673, 1976.
• Giza E, Mak W et al. A clinical and radiological study of peroneal

tendon pathology. Foot & ankle specialist. 2013 Dec;6(6):417-21

• Ogawa & Thordarson. Foot & Ankle International/Vol. 28, No.

9/September 2

• Shawen & Anderson, Tech. Foot Ankle Surg. 3:118 – 125, 2004
• Sobel, M; Bohne, WHO; O’Brien, SJ: Acta Orthop. Scand. 63:682 –

684, 1992.

e mo ryhe a lthc a re .o rg / o rtho

T HANK YOU

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