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Scientific Articles:
Steven M. Raikin, Ilan Elias, and Levon N. Nazarian
Intrasheath Subluxation of the Peroneal Tendons
J Bone Joint Surg Am 2008; 90: 992-999 [Abstract] [Full text] [PDF]
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[Read Letter to the Editor] Dr. Raikin et al. respond to Drs. Ferran and Maffulli
Steven M. Raikin, M.D., Ilan Elias, M.D., Levon N. Nazarian, M.D.   (18 June 2008)
[Read Letter to the Editor] Intrasheath Subluxation of the Peroneal Tendons
Nicholas A. Ferran, Nicola Maffulli   (18 June 2008)

Dr. Raikin et al. respond to Drs. Ferran and Maffulli 18 June 2008
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Steven M. Raikin, M.D.
Dept. of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA 19107,
Ilan Elias, M.D., Levon N. Nazarian, M.D.

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Re: Dr. Raikin et al. respond to Drs. Ferran and Maffulli

seven.raikin{at}rothmaninstitute.com Steven M. Raikin, M.D., et al.

We thank Drs. Ferran and Maffulli for their letter.

Their first question relates to the size of the split within the peroneus brevis tendon in type B pseudosubluxation. In our study(1), split / tear length ranged from 2cm to 5cm as measured under ultrasound and intra- operatively. There were only four cases in which the peroneus longus tendon was seen to subluxate through the torn peroneus brevis tendon, with no correlation between tear size, symptoms or outcome. However, not all patients with split tears had demonstrable subluxation clinically, or on ultrasound. The presence of a split tear in the peroneus brevis tendon does not automatically suggest the presence of pseudosubluxation or the need for a groove deepening procedure.

As far as the anatomy is concerned, as noted, all patients had convexity of their retro-fibular groove. While this may occur in the normal population, as you suggest, we feel that it is a predisposing factor to intra-sheath pseudosubluxation that was seen in our patients. It is our clinical impression that the convexity alters the relative amount of overhang of the fibrocartilagenous ridge which is then corrected with the groove deepening procedure. Additionally, the peroneal tendons of the patients in our study where subluxating within the intact superior peroneal retinaculum (SPR) and groove, which is a different finding from the studies you reference in your letter. In those studies,the tendons were subluxating over the fibrocartilagenous ridge. Furthermore, this procedure allows the SPR to be reattached to the bony inferior lip of the groove, maximizing ingrowth and long term stability of the surgical repair.

We do not discount your hypothesis that patients with intra-sheath pseudosubluxation of the peroneal tendons may only require reefing of the SPR and tendon split repair, but we did not perform that procedure for this study. Our study did, however, demonstrate a high success rate when the SPR reefing was combined with groove deepening.

Reference:

1. Raikin SM, Elias I, Nazarian LN. Intrasheath subluxation of the peroneal tendons. J Bone Joint Surg Am. 2008;90:992-999.
Intrasheath Subluxation of the Peroneal Tendons 18 June 2008
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Nicholas A. Ferran,
Trauma Research Fellow
University Hospital of Wales, Cardiff, UK,
Nicola Maffulli

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Re: Intrasheath Subluxation of the Peroneal Tendons

nferran{at}uku.co.uk Nicholas A. Ferran, et al.

To The Editor:

In their recent paper, Raikin et al.(1) identified two groups of patients: one in which the tendons reversibly transposed themselves within the fibular groove, and another in which the peroneus longus tendon herniated through a split in the peroneus brevis tendon. The authors found intact superior peroneal retinacula in all patients, but a distended retinaculum in nine. All patients had a convex distal fibula and received groove deepening, reefing of the superior peroneal retinaculum, and repair of any split in the tendon of peroneus brevis.

We would like some clarifications. Firstly, the authors make no mention of the size of the split in the tendon of the peroneus brevis. It would be useful to know how common the phenomenon of herniation through a split in the tendon of the peroneus brevis is, and its relationship to the size of the split.

The retrofibular groove is not formed by the concavity of the fibula, but by a relatively pronounced ridge of fibrocartilage(2). This anatomical configuration has been confirmed on histological study(3). With anatomical studies demonstrating the incidence of a flat or convex sulcus ranging from 18%(4) to 30%(5,6) in normal cadaveric specimens, the low incidence of peroneal tendon subluxation would suggest that the bony sulcus is not a predisposing factor to subluxatio(7).

With this in mind, we question the rationale for performing groove deepening procedures in such patients. We raise the possibility that the reason for a resolution of symptoms is the reefing of the distended superior peroneal retinacula and repair of the splits in the tendon of peroneus brevis.

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

References:

1. Raikin SM, Elias I, Nazarian LN. Intrasheath subluxation of the peroneal tendons. J Bone Joint Surg Am 2008;90:992-999.

2. Eckert WR, Davis EA Jr. Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am 1976;58(5):670-2.

3. Kumai T, Benjamin M. The histological structure of the malleolar groove of the fibula in man: its direct bearing on the displacement of the peroneal tendons and their surgical repair. J Anat. 2003; 203:257-262.

4. Edwards ME. The relation of the peroneal tendons to the fibula, calcaneus, and cuboideum. Am. J Anat 1928;42:213-253.

5. Poll RG, Duijfjes F. The treatment of recurrent dislocation of the peroneal tendons. J Bone Joint Surg Br 1984;66(1):98-100.

6. Mabit C. Salanne PH, Blanchard F, Boncoeur-Martel MP, Fiorenza F. The retromalleolar groove of the fibula: a radio-anatomical study. Foot and Ankle Surgery 1999;5:179-86.

7. Ferran NA, Oliva F, Maffulli N. Recurrent subluxation of the peroneal tendons. Sports Med. 2006;36(10):839-46.