Peroneal Tendon and Retinaculum Repair With Suture Augmentation: A Case Study and Technique Guide
Peroneal tendon subluxation is a condition in which one or both peroneal tendons slip out of their normal position. Injury is the primary cause, including rapid change in direction, acute forceful trauma, or repetitive stress/overuse. For many people, the issue persists due to a weak or injured retinaculum, ankle instability, or cavus foot type.1 Identifying tears in the peroneal tendons and retinaculum is necessary as well.2 Subluxing tendons can result in longitudinal tears, most often in the peroneus brevis. A 2003 retrospective review of peroneal tendon tears demonstrated peroneus brevis tears in 88% of patients, 13% in the peroneus longus, and 37% in both.3
Nonoperative treatment for peroneal tendon subluxation consists of nonsteroidal anti-inflammatory drugs (NSAIDs), rest, ice, compression, and elevation (RICE) therapy, and physical therapy.4 A lateral heel wedge can help relieve tension on the lateral ankle ligaments and peroneal tendons. Platelet-rich plasma (PRP) and/or corticosteroid injections can be utilized prior to surgical intervention, with nonoperative treatment lasting 4-6 months prior to consideration of surgical intervention.4
Surgical intervention can significantly improve functional outcomes and yield high satisfaction in patients with peroneal tendon pathology.2,5 Repairing the peroneal retinaculum is crucial to successful peroneal tendon repair. Current methods utilize anchors to reattach the superior retinaculum to the fibula, in either an open fashion or endoscopically. Concomitant groove deepening can take place in cases where the etiology of subluxation is a shallow fibular groove or tendons that are too bulky in comparison to the groove. Debridement of a bulky or low-lying muscle belly is a commonly necessity. According to a recent meta-analysis from 2022, the literature has not yet demonstrated superiority of one surgical technique over another.5 Nguyen, Drieling, and Moritz previously published a case study in 2022 in Foot & Ankle Surgery: Techniques, Reports & Cases outlining a peroneal retinaculum repair utilizing a fiber tape system.6 This article builds upon their technique.
A Deeper Dive Into a Case of Peroneal Tendon Subluxation
A 44-year-old male with past medical history of obstructive sleep apnea, nicotine dependence, hepatic steatosis, tinea pedis, and obesity (body mass index (BMI) 33) presented to our clinic complaining of left ankle pain. He described an injury a long time ago with an unknown mechanism that left him with 30 years of ankle and a “clicking sensation” with certain motions. Subjectively, he related that the ankle was unsteady on uneven surfaces. Objectively, the patient had notable subluxing peroneal tendons during circumduction of the left ankle. There was no pain with range of motion, nor did we note any gross deformities. Neurovascular status was intact, and there was no point tenderness to palpation or muscle weakness in the area of concern.
Magnetic resonance imaging (MRI) demonstrated chronic peroneal retinaculum attenuation and a longitudinal tear of the peroneus longus with lateral subluxation. The split tear of the peroneus longus extended from the lateral malleolus distally to the cuboid. The anterior talofibular and calcaneofibular ligaments were intact. The workup and exam led us to a diagnosis of left ankle instability with peroneal tendon subluxation. Initial conservative management consisted of rest, ice, stretching, supportive shoe gear, and ankle bracing. We discussed the etiology of the condition with the patient and included education on the likelihood of recurrent ankle sprains without surgical repair. After 3 months, he elected to pursue surgical management due to failure to improve with conservative measures. After medical optimization and full informed consent, he underwent a left peroneal tendon repair with retinaculum repair. Due to the chronicity of the symptoms and evidence of damage to the retinaculum, we were prepared to use the InternalBrace (Arthrex) suture augmentation to reinforce our repair.
Details on the Surgical Technique
With the patient supine on the operating table and the left leg elevated with a bump, we used an additional bump wedged under the left hip for easier lateral visualization. We applied a nonsterile tourniquet the left thigh, and prepped and draped the left leg in the usual aseptic manner. Prior to incision, we identified and marked the borders of the distal fibula. A curvilinear incision at the left lateral ankle then began at approximately 1 cm posterior to the posterior border of the fibula and extended approximately 5 cm distally following the course of the peroneus brevis. As we deepened the incision to the periosteum, we made sure to retract all vital neurovascular structures and cauterize superficial bleeding vessels as necessary.
Next, we identified the peroneal tendon sheath, along with synovitis, and sharply dissected this area with tenotomy scissors and a #15 blade. As the tendons pass around the distal fibula, we noted that the tendon sheath splits to envelop the peroneus brevis and longus along their respective courses through the foot. Intraoperatively, we saw a longitudinal split in the peroneus longus inferior to the distal aspect of the fibula. The peroneus brevis also had increased tendon bulk and a low-lying muscle belly that we sharply resected. We also resected any nonviable peroneus longus tendon prior to tubularizing the area with 2-0 polypropylene suture.
We predrilled and tapped 3 holes in the posterolateral aspect of the fibula for the knotless suture anchors. Each of the 3 sutures were passed through the reflected superior peroneal retinaculum and tightened until it approximated with the lateral border of the fibula. After repairing the superior retinaculum, we identified the posterolateral aspect of the calcaneus and placed a guidewire for the suture augmentation in the calcaneus. After confirming correct placement with fluoroscopic anteroposterior (AP) and lateral views, we predrilled and tapped the guidewire and inserted the suture augmentation anchor into the calcaneus. We passed the suture augmentation extracapsular to the biocomposite anchor repair site and inserted the augmentation anchor into a predrilled hole in the distal fibula. We cut the sutures flush to the anchors (Figure 1 above). After flushing the surgical site with saline, we closed the capsular and deep tissues layers prior to skin closure with 4-0 nylon. Total tourniquet time was 90 minutes. Postoperatively, we advised the patient to non-weight bear in a cast boot for 4 weeks and to follow up in our podiatry clinic at 2 weeks.
Reviewing the Postoperative Course
Four weeks after surgery, the patient reported some discomfort with range of motion and complained of stiffness. We prescribed physical therapy at this point. At 8 weeks, he conveyed vague discomfort around the lateral ankle, not worse with physical therapy exercises. He started wearing the cast boot and self-transitioned back to non-weight-bearing. At that time, we recommended the patient only wear his ankle brace and transition back to full weight-bearing as tolerated. He went back to work as a machinist.
At 12 weeks postop, he reported 3/10 pain at the lateral malleolus, well-controlled with ibuprofen, diclofenac, and a compression sleeve. Four months out from surgery, he endorsed tightness and had not tried any activities without the ankle brace. However, he was able to walk short distances without discomfort. At the most recent follow-up 7 months from surgery, the patient described overall improvement in mobility and strength. He is wearing new boots and the ankle brace while at work, only noting mild pain and tingling around the incision. On exam at that time, we did elicit mild paresthesias along the distal incision and pain over the proximal incision over an area of scar thickening. There was limited ankle range of motion in all directions due to stiffness, but no pain or subluxation with ankle motion.
Discussion and Lessons to Consider
Several techniques have been implemented with success in the treatment of peroneal tendon subluxation, including groove deepening, retubularization of the tendon, and isolated superior retinaculum repair, with or without an arthroscopic debridement. In our patient, we had concerns about the viability and strength of the superior retinaculum prior to surgery and we utilized the strength and reproducibility of the suture augmentation system to reinforce the repair. To our knowledge, there has been one prior study that looked at this specific application of the system for this pathology. Researchers in 2022 published a case study with this technique and yielded excellent results at 21 weeks. In their case, they repaired a compromised retinaculum after the patient re-injured the ankle after an arthroscopic Brostrom surgery. In our case, the patient was surgery-naive and instead had a long-standing history of ankle sprains and tendon subluxation.7
Numerous studies have been published on the efficacy of this suture augmentation system with lateral ankle ligament repairs. A 2022 systematic review by Piscoya and team demonstrated no significant differences in outcomes between the modified Brostrom with or without the augmentation system, including no difference in complication rates.8 The additional time spent in the OR, additional cost of the materials, and increased risk of suture material reaction all need to be considered prior to performing this type of augmentation. Thus, carefully selecting surgical candidates who would benefit from this additional repair is paramount. When using arthroscopy in Brostrom repairs, it may result in faster return to sport when done in conjunction with modified Brostrom repairs with or without this style of augmentation.9 Considering this, we feel performing arthroscopy for peroneal tendon subluxation cases may be of utility for identifying additional pathology and allowing an opportunity for less invasive debridement.
In Conclusion
Based on our experience, in cases of peroneal tendon subluxation, the suture augmentation system may be used to reinforce the peroneal retinaculum or to provide additional support to the peroneal tendons. This may help keep the tendons securely in place within their groove, preventing further subluxation and promoting proper healing.
If the retinaculum is repaired or reconstructed during surgery, the augmentation system can act as a supplemental support structure, enabling earlier motion and potentially reducing the likelihood of reinjury. Physical therapy is crucial to the recovery process after an ankle stabilization surgery. In our case, the patient transitioning back into the cast boot and non-weight-bearing at the 8-week point likely resulted in stiffness of the ankle joint and may have contributed to pain experienced after this point. Overprotection of the surgical repair may lead to prolonged rehab after a peroneal subluxation repair.
Dr. Ballew is a second-year resident with Denver Health in Denver, CO.
Drs. Gorski, Hoffman and Jerabek are attending physicians at Denver Health in Denver, CO, where Dr. Hoffman is the Director of the residency training program.
References
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