SLR - January 2011 - Shirley M. Catoire
Reference: Boykin R, Ogunseinde B, McFreely E, Nasreddine A, Kocher M. Preliminary Results of Calcaneofibular Ligament Transfer for Recurrent Peroneal Subluxation in Children and Adolescents. Journal of Pediatric Orthopedics. 30 (8); Dec 2010.
Scientific Literature Reviews
Reviewed by: Shirley M. Catoire, DPM
Residency Program: Yale/ VA Podiatric Residency Program
Podiatric Relevance
This study addresses surgical repair of peroneal subluxation in the pediatric population. Peroneal subluxation is a rare condition, especially in children. However, chronic conditions can become debilitating and may require surgical intervention. Multiple surgical interventions have been described to prevent subluxation of the tendons including grove deepening procedures of the fibula, anatomic reattachment of the retinaculum, bone blocks, tissue transfers, and rerouting the peroneals beneath the calcaneofibular ligament (CFL). This study emphasizes the rerouting of the peroneal tendons beneath the CFL to prevent disruption if the fibular physis in skeletally immature patients.
Methods
A review of all patients that underwent surgical intervention of isolated peroneal subluxation with re-routing the peroneal tendons beneath the CFL was conducted. The time frame for surgical intervention was January 2003 to January 2007. All skeletally matured patients were excluded from the study. A total of 9 pediatric cases (7 patients) were included. Postoperative assessment of pain was determined at follow up clinical visits. Patients included in the study completed Foot and Ankle Ability Measure (FAAM) and American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS).
The senior author conducted all surgical procedures. Surgical intervention included detachment of CFL from the fibula, transposition of peroneals, and reattachment of CFL above the peroneals with imbrications of the superior peroneal retinaculum. All patients were placed into a short leg cast and non-weight bearing for 2 weeks. Patients were then transitioned to walking boot and dorsiflexion/plantarflexion range of motion exercise was started. At week 6, the patients were given ankle brace and allowed to start inversion/eversion exercises. Patients were allowed to return to sports at week 12.
Results
The review yielded 9 pediatric cases (7 patients) for review. The mean age was 12.4 at the time of surgery. There were 5 females and 2 males included in the study. All patients initially had conservative therapy that included immobilization with cast or walking boot, rest, and pain control. The fibular physis was open in 100% of the cases.
Average clinical follow up was 20.9 months. For all 9 ankles, there was no recurrent instability noted at the most recent follow up. All patients had a full return function including inversion and eversion motions as well as sport activities. There was no incidence of physeal arrest.
Only 6 out of 9 ankles completed the questionnaires. Of the 6 completed surveys, the average FAAM score was 90.1, the AOFAS score was 86. Most patients reported occasional pain, but a stable ankle.
Conclusion
Peroneal subluxation is a rare entity and may be overlooked in the pediatric population. This study demonstrates a viable option for surgical repair in a skeletally immature patient.