Tendoscopic Double-Row Suture Bridge Peroneal Retinaculum Repair for Recurrent Dislocation of Peroneal Tendons in the Ankle

Abstract

Traumatic dislocation of peroneal tendons in the ankle is an uncommon lesion that mainly affects young adults. Unfortunately, most cases lead to recurrent dislocation of the peroneal tendons of the ankle (RPTD). Therefore, most cases need operative treatment. One of the most common operative procedures is superior peroneal retinaculum (SPR) repair. Recently, surgery for RPTD has been achieved with less invasive arthroscopic procedures. In this article, tendoscopic surgery for RPTD using a double-row suture bridge technique is introduced. This technique consists of debridement of the lateral aspect of the fibula under an intrasheath pseudo-cavity, suture anchor insertion into the fibular ridge, and reattachment of the SPR to the fibula using a knotless anchor screwed into the lateral aspect of the fibula. This technique mimics the double-row suture bridge technique for rotator cuff tear repair. The double-row suture bridge technique requires more surgical steps than the single-row technique, but it provides a wider bone-SPR contact surface and tighter fixation than the single-row technique. This procedure is an attractive option because it is less invasive and has achieved results similar to open procedures.

Dislocation of peroneal tendons is a relatively rare traumatic injury, but it can also occur as a sports injury. Although some reports have clarified the efficacy of nonoperative treatment for acute peroneal tendon dislocation,1, 2 it is often misdiagnosed as an ankle sprain and treated by early mobilization, which then results in chronic peroneal tendon instability. Recurrent posterolateral ankle instability and pain can severely affect patients' activities.

Since van Dijk and Kort³ reported the use of a peroneal tendoscope, several reports on peroneal tendoscopic surgical procedures have been published. Vega et al.⁴ reported tendoscopic fibular groove–deepening surgery for recurrent subluxation of the peroneal tendons. Moreover, Guillo and Calder,⁵ Lui,⁶ and Miyamoto et al.⁷ reported tendoscopic repair of the retinaculum for peroneal tendon subluxation or dislocation. However, they used only a single-row method. In arthroscopic rotator cuff repair surgery, a double-row suture bridge results in a significantly higher tendon healing rate than a single-row repair.⁸ The purpose of this study was to introduce and examine the utility of the tendoscopic double-row suture bridge peroneal retinaculum repair for peroneal tendon dislocation, which has not been previously reported.

Surgical Technique

Surgery is performed with the patient under lumbar spinal anesthesia or general anesthesia. The patient is placed in the lateral decubitus position. A pneumatic tourniquet is placed on the proximal femur before surgery in case of vascular injury, but it is not generally used. A flow pump system (Continuous Wave II Arthroscopy Pump; Arthrex, Naples, FL), which is adjusted from 20 to 50 mm Hg, is used throughout the surgical procedure. The following landmarks are marked: the lateral malleolus, the base of the fifth metatarsal bone, and the running course of the tendon of the peroneus brevis (Fig 1). An ultrasound machine (Noblus; Hitachi Aloka, Tokyo, Japan) and a high-frequency linear probe (L64 linear probe, 5 to 18 MHz; Hitachi Aloka) are prepared with a sterile ultrasound probe cover and sterile gel. Before a skin incision is made, the position of the peroneal tendons is checked by ultrasound (Table 1). Some saline solution is injected into the peroneal tendon sheath under ultrasound assistance (Fig 2, Video 1). A proximal portal is made 2 fingerbreadths proximal to the lateral malleolus. A 3- to 5-mm incision is made in the skin with a No. 11 blade in the same direction as the course of the tendons to avoid injury. After blunt dissection, a 2.5-mm 30° short endoscope (ConMed Linvatec, Largo, FL) is inserted from the proximal portal under ultrasound assistance, and the arthroscope is pushed distally, beyond the tip of the malleolus. The proximal portal is usually used as the viewing portal. The distal portal is placed 1 fingerbreadth distal to the lateral malleolus under arthroscopic transillumination guidance. The tendons and intrasheath pseudo-cavity can be seen, and the peroneal tendons can be checked with the probe (Fig 3). In patients with tenosynovitis, a tenosynovectomy is performed with a shaver and/or a radiofrequency device. The lateral surface of the lateral malleolus, where the retinaculum has been stripped off, is cleaned using a shaver (Powermini 2.9-mm Full Radius Blade, Dyonics Powermini Shaver System; Smith & Nephew, Andover, MA) and/or a radiofrequency device (2.3-mm side probe [short], VAPR 3 system; DePuy Mitek, Westwood, MA), and it is slightly roughened with an arthroscopic burr (Powermini 2.9-mm Abrader Burr, Dyonics Powermini Shaver System; Smith & Nephew) (Fig 4). A drill guide (1.4-mm JuggerKnot Instrument Kit; Biomet Japan, Tokyo, Japan) or suture anchor is introduced into the fibular ridge through the portals, and a suture anchor (1.4-mm JuggerKnot) is then inserted (Fig 5). An 18-gauge needle, into which a shuttle relay has been looped (No. 2-0 Prolene; Johnson & Johnson, Tokyo, Japan), is used as a suture lasso to thread through the skin and the superior peroneal retinaculum (SPR). The nylon loop is pulled out from the portal using a grasper (Suture Manipulator Grasper; DePuy Mitek) (Fig 6, Video 1). One limb of the suture anchor is put into the nylon loop outside of the skin, and then the opposite end of the nylon loop is pulled out through the portal. This allows the nylon loop leads on 1 limb of the suture anchor to penetrate the SPR. With the same technique, 6 passes are made (Fig 7), and 6 threads are picked up subcutaneously. The sutures are tightened by the sliding knot to reattach the SPR to the fibula, and 1 limb of each suture anchor is cut with a suture cutter. An additional skin incision is made on the lateral malleolus for the suture bridge technique. A drill for a 3.5-mm PEEK (polyether ether ketone) SwiveLock knotless anchor (Arthrex) is inserted into the fibula from the distal side at an angle of 45° (Fig 8). All anchor threads are passed into the eyelet of the anchor, and the anchor eyelet is brought to the top edge of the drill hole. The threads are pulled to the desired tension, and 1 thread is marked at the level of the black laser line on the anchor. Then, the anchor is pulled back, and the eyelet is placed at the marked point on the thread. Finally, the anchor is inserted into the fibula. After the final anchor has been correctly inserted, the remnant thread tails are cut with a scalpel (Video 1).

Fig 1.

Landmarks and portals: proximal portal (portal 1) and distal portal (portal 2). Portal 1 is placed 2 fingerbreadths proximal to the lateral malleolus tip. Portal 2 is placed 1 fingerbreadth distal to the lateral malleolus tip.

Table 1.

Surgical Steps, Pearls, and Pitfalls

Surgical Steps	Pearls	Pitfalls
Insertion of tendoscope	Using ultrasonography makes it easier to introduce the tendoscope.	Blind insertion of the scope can destroy the superior peroneal reticulum.
Cleaning of lateral malleolus	The arthroscopic burr is used just on the lateral malleolus so as not to damage the superior peroneal retinaculum or fibrocartilaginous ridge.	Poor visualization may lead to damage to the superior peroneal retinaculum or fibrocartilaginous ridge.
Insertion of suture anchors	Suture anchors are inserted into the fibrocartilaginous ridge. Most of the distal anchor is inserted through the distal portal, and the other 2 anchors are inserted through the proximal portal. Pulling the suture allows confirmation that the suture anchors are inserted tightly into the lateral malleolus.	If the suture anchors are inserted into the lateral malleolus shallowly, they will slip out from the bone.
Suture lasso using 18-gauge needle and No. 2-0 Prolene	With the peroneal tendon sheath not too tight, an 18-gauge needle is passed through the superior peroneal retinaculum.	The surgeon must be careful not to damage the sural nerve.
Knot tying	Knot tying of the most distal anchor is performed through the distal portal, and knot tying of the 2 other anchors is performed through the proximal portal.	The surgeon must be careful not to damage the superior peroneal retinaculum when threads are picked up subcutaneously.
Suture bridge	A drill for a knotless anchor is inserted into the fibula from the distal side at an angle of 45°. The threads are pulled to the desired tension, and 1 thread is marked at the level of the black laser line on the anchor. Then, the anchor is pulled back, and the eyelet is placed at the marked point on the thread. Finally, the anchor is inserted.	If a drill for the knotless anchor is inserted into the fibula from the distal side at a nearly vertical angle, the medial wall of the fibula might be fractured. It is important to maintain the tension of the threads. If the tension is too weak, the superior peroneal reticulum will not fit correctly. If it is too strong, the knotless anchor can sometimes break.

Fig 2.

(A) Macroscopic findings showing saline solution injection under ultrasonographic guidance. (B) Ultrasonographic findings. Before a skin incision is made, the position of the peroneal tendons is checked by ultrasound. Some saline solution is injected into the peroneal tendon sheath under ultrasound assistance to introduce the arthroscope into the peroneal tendon sheath. (N, needle; PT, peroneal tendon.)

Fig 3.

Tendoscopic findings of false pouch (FS). The arthroscope is used in portal 1 and the instruments in portal 2. (FCR, fibrous cartilaginous ridge; PBT, peroneal brevis tendon; PLT, peroneal longus tendon.)

Fig 4.

Cleaning of lateral surface of lateral malleolus (LM). The lateral surface of the LM under a false pouch is slightly roughened with an arthroscopic burr (AB).

Fig 5.

Insertion of suture anchor. The arrowheads indicate the drill guide. Suture anchors (1.4-mm JuggerKnot) are inserted into the fibrocartilaginous ridge (FCR) through the portals.

Fig 6.

Shuttle relay passing through superior peroneal reticulum. An 18-gauge needle, into which a shuttle relay has been looped (No. 2-0 Prolene), is used as a suture lasso to thread through the skin and the superior peroneal retinaculum. (FCR, fibrocartilaginous ridge; FP, false pouch.)

Fig 7.

Macroscopic findings showing 6 sutures through superior peroneal retinaculum. Three suture anchors are inserted into the fibula, and all 6 threads penetrate the superior peroneal retinaculum and the skin.

Fig 8.

Suture bridge using knotless anchor. All anchor threads are passed into the eyelet of a knotless anchor. The threads are pulled to the desired tension, and the anchor is inserted into the fibula.

For postoperative care, the patient is put in a short leg cast for 3 weeks (non–weight-bearing cast for 10 days and weight-bearing cast with heel for 11 days), but movement of the toes is permitted 1 day after surgery. Sutures are removed after 10 days. After the cast is removed, ankle range of motion, proprioception, and strengthening training are initiated. If there is no swelling or pain, jogging is permitted 6 to 8 weeks after surgery. Return to full sports activity is permitted approximately 3 months after the operation.

Discussion

Many types of operations have been described for repair of peroneal tendon dislocation, such as anatomic reattachment of the retinaculum,9, 10, 11, 12 bone block procedures,¹² tissue transfer procedures,13, 14 and groove deepening.¹⁵ Bone block procedures may lead to complications such as fracture of the graft or the lateral malleolus, intra-articular placement of the screws, or recurrence. Tissue transfer procedures need to sacrifice normal structure and require nonanatomic procedures. Groove deepening is not indicated when the peroneal groove is not shallow. Therefore, we used anatomic reattachment of the retinaculum.

The benefits of a tendoscopic approach over an open approach have already been shown in other ankle conditions, such as ankle fusion, cheilectomy, and debridement. The tendoscope improves the management of associated intratendon sheath lesions (Table 2). Studies have shown that converting to a tendoscopic technique can be demanding, with a long learning curve and an increase in surgical time. However, the advantages of preserving the soft-tissue envelope and the improved visualization outweigh these issues. One can see improved recovery, less pain, a lower rate of soft-tissue complications, and improved healing through better preservation of the blood supply. With this peroneal tendoscopic procedure, we can see the fibular malleolar groove. If the patient has a shallow groove, we can deepen the peroneal tendon groove under tendoscopic observation. We can also assess the condition of the peroneal tendons. If the peroneal tendon has a longitudinal tear, it can be repaired.

Table 2.

Advantages, Risks, and Limitations of Technique

Advantages

We can more clearly assess the condition of intratendon sheath lesions.

Our tendoscopic procedure leads to earlier recovery, less pain, a lower rate of soft-tissue complications, and improved healing through better preservation of the blood supply.

The double-row suture bridge technique used in this procedure has a larger bone-retinaculum contact surface than the single-row technique.

Risks and limitations

Tendoscopic surgery needs a long learning curve.

This procedure requires a longer operation time than open procedures.

The double-row suture bridge technique in this procedure requires 1 more skin incision.

A knotless anchor is too large for certain patients, especially Japanese women.

In young children who still have epiphyseal lines, a knotless anchor cannot be used.

The peroneal tendon sheath is thin and shallow beneath the skin. Thus, when performing tendoscopic operations, surgeons sometimes have difficulty with inserting the tendoscope into the peroneal tendon sheath, and it is even more difficult in the presence of a subcutaneous irrigation fluid leak. Therefore, we used ultrasonographic guidance. Before insertion of a trocar, we injected saline solution into the peroneal tendon sheath under ultrasonographic guidance, which facilitated the procedure.

Some tendoscopic procedures for recurrent dislocation of peroneal tendons have been reported. Vega et al.⁴ reported tendoscopic fibular groove–deepening surgery for recurrent subluxation of the peroneal tendons. However, if patients have a concave fibula, fibular groove deepening is not reasonable. On the other hand, Guillo and Calder,⁵ Lui,⁶ and Miyamoto et al.⁷ reported tendoscopic repair of the retinaculum for peroneal tendon subluxation or dislocation. However, these surgical techniques were only single-row methods. In an arthroscopic rotator cuff repair procedure, a double-row suture bridge resulted in a significantly higher tendon healing rate than a single-row repair.8, 16 Moreover, double-row suture bridge technique seemed superior to the single-row technique in terms of the bone-tendon contact surface and pressure in an in vitro biomechanical study.¹⁷ Therefore, we mimicked the double-row suture bridge technique used for rotator cuff tear and placed a fully threaded, knotless anchor (3.5-mm PEEK SwiveLock) into the lateral aspect of the fibula. However, this anchor is sometimes too large for certain patients, especially Japanese women. Furthermore, in young children who still have epiphyseal lines, this knotless anchor cannot be used. We hope that a smaller anchor will be developed for shorter patients.

In conclusion, we have described a tendoscopic double-row suture bridge peroneal retinaculum repair. This procedure requires some training, but it seems to be an alternative to open procedures and has more advantages than other tendoscopic surgical procedures.

Supplementary Data

Video 1

The patient is placed in the lateral decubitus position. A proximal portal (usually used as the viewing portal) is made 2 fingerbreadths proximal to the lateral malleolus. A distal portal (usually used as the working portal) is made 1 fingerbreadth distal to the lateral malleolus tip.