SLR - March 2011 - Robert C. Andersen
Reference: Boykin RE, Ogunseinde B, McFeely ED, Nasreddine A, Kocher MS. Preliminary results of calcaneofibular ligament transfer for recurrent peroneal subluxation in children and adolescents. J Pediatr Orthop. 2010 Dec;30(8):899-903.
Scientific Literature Review
Reviewed by: Robert C. Andersen, DPM, PGY-3
Residency Program: Southern Arizona VA Healthcare System, Tucson, AZ
Podiatric Relevance:
Patients with subluxation of the peroneal tendons, although uncommon, may be seen in the typical podiatric practice. The etiology is thought to be due to a rupture of the superior peroneal retinaculum. This condition may also be associated with fractures of the lateral malleolus or a pre-existing shallow inferior peroneal groove. Many operative techniques have been described, but there is little data evaluating the surgical management and outcome in the adolescent patient with open physis.
Methods:
The authors of this study performed a retrospective review spanning a period of 5 years from patients who presented to their clinic. They found 9 cases of recurrent peroneal subluxation refractory to non-operative treatment. A total of 7 children were found with a mean age of 12 who presented with traumatic and atraumatic etiologies. Ages ranged from 6.9 to 17.1 years old, 5 of which were female and 2 male. All patients failed nonoperative treatment and were treated operatively with calcaneofibular ligament (CFL) transfer rerouting the peroneal tendons underneath the CFL. All patients were observed in follow-up and sent validated outcomes questionnaires, including the Foot and Ankle Ability Measure and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale. Skeletally mature patients or those who were lost to follow-up were excluded from the study.
Results:
Clinical follow-up ranged from 12-35 months with a mean of 20.9 months. At follow-up, all patients returned to normal activities including sports with no incidence of recurrence. There were a total of two complications, one pt had a postoperative infection and another required revisional surgery secondary to fibrosis. 66.6% (6 of the 9 ankles) returned outcome surveys. The average Foot and Ankle Ability Measure activities of daily living score was 90.8 (±4.4) and the sports subscale was 62.5 (±9.3). The mean American Orthopaedic Foot and Ankle Society score was 86 (±3.2).
Conclusions:
Peroneal subluxation is an uncommon condition in pediatric and adolescent athletes. Although this condition has been reviewed extensively in the literature for the adult, little is written about the adolescent with open physes. For these patients, CFL transfer over the peroneal tendons should be considered as it provides excellent stability, a low rate of recurrent subluxation, and good functional outcomes without risk of injury to the distal fibular physis which can occur with distal fibular osteotomy or groove deepening procedures. Patients should undergo early physical therapy as post-operative stiffness is a possible complication.