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 e mo ryhe a lthc a re .o rg / o rtho
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%) of 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 Fibula 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 Fibula a c ute re pa ir
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 2 limbs of suture in she ath to c r e ate preseved e nough spac e for gliding
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
• 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. • e s a t the fina l fo llo w-up Impr ove me nts in AOF AS and VAS sc or 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 oximate ly 3 months in oups . Me a n to urniq ue t time in g ro up B wa s sig nific a ntly both gr 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 oove De e pe ning e mo ryhe a lthc a re .o rg / o rtho
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