SLR - July 2011 - Dyane E. Tower
Reference: Boykin, R. E., Ogunseinde, B., McFeely, E. D., Nasreddine, A., Kocher, M. S. (2010). Preliminary Results of Calcaneofibular Ligament Transfer for Recurrent Peroneal Subluxation in Children and Adolescents. Journal of Pediatric Orthopaedics, 30, 899-903.
Scientific Literature Review
Reviewed by: Dyane E. Tower, DPM
Residency Program: North Colorado Podiatric Surgical Residency
Podiatric Relevance:
While peroneal tendon subluxation is relatively uncommon, especially in the pediatric and adolescent population, surgical intervention is often required to prevent recurrent subluxation. This article offers preliminary results on a surgical procedure to prevent recurrent peroneal tendon subluxation while preserving the integrity of the distal fibular physis in the pediatric and adolescent population.
Methods:
A retrospective chart review was performed on 7 patients (9 ankles) with open distal fibular physes and recurrent painful isolated peroneal tendon subluxation. These patients failed conservative treatment measures including immobilization, rest and pain control and subsequently underwent surgical intervention to reroute the peroneal tendons under the calcaneofibular ligament (CFL). The surgical procedure, with tourniquet hemostasis control, included detachment of the CFL at its fibular insertion, transposition of the CFL from a deep to superficial position in relation to the peroneal tendons, reattachment of the CFL to the fibular periosteum and imbrication of the superior peroneal retinaculum with Ethibond sutures. Intra-operative range of motion was assessed to ensure adequate motion and lack of residual peroneal tendon subluxation. Post-operative protocol included 2 weeks non-weight bearing in a short leg cast followed by 4 weeks of protected weight bearing as tolerated in a walking boot. Physical therapy was initiated at 2 weeks post-op to include dorsiflexion-plantarflexion exercises and at 6 weeks post-op, inversion-eversion exercises were started. A brace was worn during sports after 6 weeks and return to full sporting activities was allowed at 12 weeks post-op. The Foot and Ankle Ability Measure and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scales were used to assess outcome.
Results:
The charts of 7 patients (9 ankles) with recurrent painful peroneal tendon subluxation were reviewed. Average age at time of surgery was 12.4 years and average follow-up was 20.9 months. No recurrent subluxation or instability was identified during the follow-up period. Full inversion-eversion strength returned by 12 weeks post-op. Those subjects participating in sports returned with no recurrence of subluxation but some limitation of recreational activity, especially on uneven terrain. The Foot and Ankle Ability Measure scores were 90.9/100 for activities of daily living and 62.5/100 for the sports score and the AOFAS score was 86/100 at the most recent follow-up. Some subjects complained of mild pain and stiffness of the ankle, but that it felt stable.
Conclusions:
Osseous surgical procedures to prevent recurrent peroneal tendon subluxation in pediatric and adolescent populations have the potential to arrest physeal growth of the distal fibula, resulting in valgus deformity of the ankle. The soft tissue procedure described in this article offers a stable reconstruction with restraint of peroneal tendon subluxation without disrupting the distal fibular physis in a skeletally immature patient.