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

Relationship Between Peroneal Tendons and Anterior Talofibular Ligament

Background: Anterior talofibular ligament (ATFL) injuries are the most common in ankle torsional injuries. ATFL and peroneal tendons are both important stabilizers of lateral ankle joint. We aimed to evaluate peroneal tendons and ATFL. Methods: Fifteen nonpaired leg of fresh frozen cadavers were assessed in this study. After harvesting, ATFL diameters were measured at three points by calipers, these are fibular side, intermediate side and talar side. The mean of these three measurements were assessed and tissue a 15 lb load was applied to the peroneal tendons for 10 minutes, and the transverse diameters were measured by folding the thickest part of the tendon in a double-strand. Results: 5 single bundle, 8 double-bundle and 2 three bundles of ATFL were obtained after dissection. . There was no correlation between ATFL diameter, peroneus longus, peroneus brevis and total tendon diameters of peroneus longus and peroneus brevis in women (p> 0.05). A strong correlation was found between ATFL diameter, peroneus longus (r: 0.95), peroneus brevis (r: 0.81) and total tendon diameters of peroneus longus and peroneus brevis (r: 0.92) in men. Conclusion: Relationship between the diameter of the ATFL and peroneal tendons diameters were evaluated and a correlation was observed in males, while no correlation was observed in females.

Load to Failure and Stiffness of Interference Screw vs Pulvertaft Weave for Distal Fixation in Peroneal Allograft Reconstruction

Background: Allograft reconstruction of the peroneal tendons is an option for treatment of major tears of 1 or both peroneal tendons. No consensus on a superior distal fixation method has been reported. The purpose of the study was to compare load to failure and stiffness of a Pulvertaft weave (PTW) through a residual tendon stump to direct-to-bone interference screw (IS) fixation. Methods: Fifteen pairs of long leg cadaver specimens were used. All grafts were secured proximally to the peroneus brevis myotendinous junction via a PTW technique. Distally, the tendons were either sutured to the peroneus brevis stump via PTW or secured to the base of the fifth metatarsal via IS. Stiffness (slope of force/displacement) was measured for the intact tendon and after reconstruction, and finally each specimen was loaded to failure. Results: Mean load to failure was significantly higher in the PTW group compared with the IS group (373.6 ± 265.5 N vs 150.1 ± 93.1 N; P = .01). The PTW and IS groups had significantly lower stiffness compared with the intact specimens ( P < .001). There was no statistical significance in stiffness between the 2 techniques ( P = .96). Conclusion: The PTW technique yielded higher load to failure in comparison to IS. There was no difference in overall construct stiffness between both techniques. Both constructs demonstrated 19% decrease in stiffness compared to the intact state. Clinical Relevance: The PTW and IS constructs were biomechanically similar, and these results suggest that both should be moderately overtensioned to compensate for an inherent decreased initial stiffness.

Peroneal Sheath Volumes Are Greater in Patients With Peroneal Pathology Compared With Controls

Background Peroneal tendon pathology is common. Several factors have been implicated, including low-lying muscles and accessory tendons. Studies have reported on the presence and length measurements of these structures. This study evaluates volume measurements within the sheath using magnetic resonance images for patients with operatively treated peroneal tendon pathology and control patients without peroneal disease. Methods Fifty-one patients with peroneal tendon pathology and 15 controls were included. The volumes of the peroneal sheath, peroneal tendons, peroneal muscle, and accessory peroneus tendons were measured. The distal extent of the peroneus brevis (PB) muscle was measured. Volume and length measurements were then compared. Results The mean PB muscle length from the tip of the fibula was 5.55 ± 2.5 mm (peroneal group) and 11.79 ± 4.07 mm (control) ( P = .017). The mean peroneal sheath volume was 7.06 versus 5.12 mL, respectively ( P = .001). The major contributors to this increased volume was the tenosynovitis (3.58 vs 2.56 mL, respectively; P = .019), the peroneal tendons (2.17 vs 1.7 mL, P = .004), and the accessory peroneus tendon + PB muscle (1.31 vs 0.86 mL, P = .023). Conclusion The current study supports that the PB muscle belly is more distal in patients with peroneal tendon pathology. The study also demonstrates increased total volume within the peroneal sheath among the same patients. We propose that increased volume within the sheath, regardless of what structure is enlarged, is associated with peroneal tendon pathology. Further studies are needed to determine if debridement and decompression of the sheath will result in improved functional outcomes for these patients. Levels of Evidence Level III: Case control imaging study

The Ellis Jones Method of Treating Chronic Peroneal Subluxation: Revisited and Colorized After 87 Years

Chronic cases of peroneal subluxation typically call for surgical treatment; however, research on current surgical procedures suggests nonuniformity. The purpose of this study is to remind surgeons of the efficacy of an older surgical method by using the case of a selected patient. In this study, the Ellis Jones procedure was performed on a patient who had been suffering from a chronic peroneal subluxation for 22 years, since, in this particular case, other approaches were deemed likely to be unsuccessful. The patient had hypertrophied, frayed, and swollen tendons, which were unsuitable to be rerouted, whereas the superior peroneal retinaculum was diminished and deepening procedures would not be able to establish sufficient volume for retaining the hypertrophied tendons. After the debridement and repair of the peroneal tendons, ¼ of the lateral Achilles tendon was split, passed through a hole in the fibula, and sutured onto itself, and the subluxation path of the peroneal tendons was closed with an effective tendon barrier. The patient returned to work after 8 weeks of the surgery and was followed up for 4 years postoperatively. On selected patients, the Ellis Jones surgical method might therefore still be applied. Levels of Evidence: Level V