Abstract
Purpose
This study evaluated the clinical outcome of non-operative treatment of peroneal tendon dislocations.
Methods
A systematic review of literature was performed.
Results
Six studies were included. Redislocation rates differed between treatments: taping ≥ 3 weeks; 18/30 (60%) patients. Plaster cast ≥ 4 weeks; 5/13 (32%) plaster cast ≥ 6 weeks; 1/6 (17%). Strapping or taping treatment indicated a higher rate of pain and instability and a lower rate of ability to return to former activity.
Conclusions
A non-weight bearing cast ≥ 6 weeks was successful in 5/6 patients. A non-weight bearing cast might be a good alternative for surgical intervention.
Level of Clinical Evidence: Level IV, systematic review of level IV studies.
Keywords: Peroneal tendons, Peroneal, Luxation, Dislocation, Subluxation, Non-operative therapy
1. Introduction
Peroneal tendon dislocation is an injury of the lateral ankle. It generally occurs after a dorsiflexion in a slightly everted foot, followed by a strong contraction of the peroneal muscles. This sudden action can be forceful enough to damage the superior peroneal retinaculum, resulting in an anterior luxation of the peroneal longus tendon and the peroneal brevis tendon over the lateral malleolus. The injury is associated with sports requiring fast cutting, like skiing, ice-skating, soccer, basketball, rugby and gymnastics.1, 2, 3
Acute peroneal tendon dislocation presents with oedema, tenderness and pain at the lateral side of the ankle. Some patients have a chronic presentation, including ankle instability and recurrent snapping or popping sensation. The clinical presentation of peroneal tendon dislocation is easily confused with lateral ankle sprains. Consequently, peroneal tendon dislocation is likely to be missed and underdiagnosed.4 The first description of this injury is published by Monteggia in 1803.5 Roughly 70 years later, treatment applied for this injury was first presented by Blanulet and Gutierrez.6,7 Nowadays, numerous articles have been published concerning the surgical treatment of both acute and chronic peroneal tendon dislocation.3,8, 9, 10, 11 Conversely, fewer studies have been published that assessed the clinical outcome of non-operative treatment. In many publications, non-operative treatment is presumed to be associated with a higher rate of recurrence and failure.3,4,12,13 Although higher rates of failure are often mentioned, no study reviewed the current evidence for non-operative treatment. Accordingly, there might be a literature knowledge gap. In order to provide the best patient-fit treatment, a better understanding of non-operative treatment would have clinical significance.
For this reason, we performed a review of literature to assess all evidence considering the clinical outcome of non-operative treatment of peroneal tendon dislocations.
2. Materials and methods
2.1. Search strategy
For this study no Institutional Review Board approval was needed. In February 2019, articles were systematically explored by an independent biological data analyst searching the Embase, Medline OVID, Web-of-science, Cinahl Ebsco, PubMed publisher, Cochrane and Google scholar electronic databases (appendix). In addition, references of identified or review studies were examined to identify potentially eligible articles. The search included randomized controlled trials, cohort studies, case series and case reports addressing patients of all ages who obtained non-operative treatment for acute or chronic peroneal tendon dislocation. The search was limited to English and Dutch language studies and no publication date restrictions were imposed. Studies were excluded if they referred to diagnostic techniques, peroneal nerve injuries, co-existing injuries, tendon ruptures and surgical intervention only.
2.2. Study selection
Two independent reviewers performed a screening based on title and abstract. Disagreements between the reviewers were discussed and resolved by consensus. The full–text versions from the remaining studies were assessed for eligibility by both reviewers.
2.3. Data extraction and risk of bias assessment
Data on study design, patient demographics, duration of treatment and intervention characteristic were extracted from the included studies. The primary outcome was the occurrence of recurrent dislocation of the peroneal tendons. Secondary outcomes were pain, the ability to return to former activity and persistent sensation of instability. Additionally, patients were noted who underwent late surgical repair after initial non-operative therapy.
All studies were assessed by two independent reviewers using the Cochrane Collaboration's tool for assessing risk of bias.14 Studies were scored by assigning a low, high or unclear risk of bias addressing the sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data and selective outcome reporting.
3. Results
3.1. Literature search and selection
The literature search of PubMed, EMBASE, the Cochrane library, Medline Ovid, Web-of-science, Cinal Ebsco and Google Scholar resulted in 3516 studies. After the removal of duplicates, 1516 studies remained. 23 studies were obtained for detailed evaluation. After evaluation, 6 studies were included for the analysis.15, 16, 17, 18, 19, 20 No additional records were identified through other sources (Fig. 1).
Fig. 1.
Flowchart of literature search.
3.2. Baseline characteristics
The studies were published between 1962 and 2011, including two retrospective cohort studies,16,18 two case series15,20 and two case reports17,19 (Table 1). In total, 80 patients were treated non-operatively, ranging from 12 to 57 years old.
Table 1.
Baseline study characteristics.
| study | Study design | Patient demographics | Intervention characteristics | duration of treatment | Follow up |
|---|---|---|---|---|---|
| Eckert et al. 197615 | Case series | N = 3 Mean age = unclear Gender M/F = unclear |
Tape | unclear | unclear |
| N = 4 Mean age = unclear Gender M/F = unclear |
plaster cast | 4 weeks | unclear | ||
| Escalas et al. 198016 | Retrospective cohort study | N = 38 Mean age = 23,6 (13–50) Gender M/F = 13/18 |
Immobilization in compressive bandage | unclear | unclear |
| McLennan et al. 198018 | Retrospective cohort study | N = 14 Mean age = 25 (13–55) Gender M/F = 9/5 |
Non-weight bearing Tape |
3 weeks | 18,86 months (7 months–36 months) |
| N = 1 Mean age = 23 Gender M/F = 0/1 |
Plaster cast | unclear | 16 months | ||
| Stover et al. 196220 | Case series | N = 4 Mean age = 24 (15–41) Gender M/F = 3/1 |
Tape, in neutral position | 4 weeks | unclear |
| N = 5 Mean age = 24,6 (21–28) Gender M/F = 3/2 |
Tape, in neutral position | 6 weeks | unclear | ||
| N = 5 Mean age = 32,4 (20–57) Gender M/F = 3/2 |
Non-weight bearing plaster cast | 6 weeks | unclear | ||
| N = 2 (1 lost to follow-up) Mean age = 16 Gender M/F = 1/0 |
Walking cast | 6 weeks | unclear | ||
| N = 2 (1 lost to follow-up) Mean age = 29 Gender M/F = 1/0 |
Plaster cast | 2 weeks | unclear | ||
| Klos et al. 201117 | Case report | N = 1 Mean age = 23 Gender M/F = M |
Anti-inflammatories, rest, physical therapy, brace | 8 weeks | 6 months |
| Siegel et al. 200819 | Case report | N = 1 Mean age = 12 Gender M/F = 1/0 |
Lateral malleolar cup | 6 months | 6 months |
Types of treatment varied across studies: three studies reported the use of tape15,18,20 and two studies treated initially with non-weight bearing plaster cast.18,20 Bracing, immobilization in a compressive bandage and the use of a malleolar cup was reported.16,17,19 The duration of treatment varied across all studies.
Stover et al.20 described 19 patients. However, only 16 patients received non-operative treatment. Two patients were lost to follow-up and one patient underwent early surgical intervention. McLennan et al.18 reported 16 patients of which one patient was treated operatively. Therefore the number of patients treated non-operatively is 1620 and 15.18 The total follow-up time after treatment is unclear in three studies.15,16,20 One study18 reported a mean follow-up time of 18,86 months with a range of 7–36 months after treatment with non-weight bearing tape. One patient treated with a plaster cast had a total follow-up time of 16 months. Klos et al.17 and Siegel et al.19 described a follow-up time of 6 months.
3.3. Primary and secondary outcome
The results of 78 patients, which were treated non-operatively, are summarized in Table 2. Eckert et al.15 treated 7 patients with either tape of plaster cast (Table 1) resulting in a 57.1% (4/7) rate of recurrent dislocation and 85.7% (6/7) of the patients indicated pain and sensation of instability. Escalas et al.16 treated 38 patients with compressive bandage. Out of 38 patients, 28 (73.7%) patients experienced recurrent dislocation and underwent late surgical repair. McLennan et al.18 treated 14 patients with non-weight bearing tape, resulting in 57.1% (8/14) recurrent dislocation. One patient treated with a plaster cast had recurrent dislocation and one patient treated with non-weight bearing tape was unable to return to former activity. The patient treated with a plaster cast experienced pain but was able to return to former activities. In 46.7% (7/15) of the patients late surgical repair was required.
Table 2.
Primary and secondary outcome, recurrent dislocation, pain, inability to return to former activity, sensation of instability and late surgical repair.
| study | Intervention characteristics | duration of treatment | Recurrent dislocation | pain | Inability to return to former activity | Sensation of instability | Late surgical repair |
|---|---|---|---|---|---|---|---|
| Eckert et al. 197615 | Tape or plaster cast | 4 weeks | (4/7) 57% | (6/7) 86% | (6/7) 86% | ||
| Escalas et al. 198016 | Immobilization in compressive bandage | unclear | (28/38) 74% | (28/38) 74% | |||
| McLennan et al. 198018 | Non-weight bearing Tape | 3 weeks | (8/14) 57% | (1/14) 0,1% | (7/15) 47% | ||
| Plaster cast | unclear | (1/1) 100% | (1/1) 100% | (0/0) 0% | (0/0) 0% | ||
| Stover et al. 196220 | Tape, in neutral position | 4 weeks | (4/4) 100% | (1/4) 25% | (0/4) 0% | (3/4) 75% | |
| Tape, in neutral position | 6 weeks | (2/5) 40% | (0/5) 0% | (1/5) 20% | (1/5) 20% | ||
| Non-weight bearing plaster cast | 6 weeks | (0/5) 0% | (0/5) 0% | (0/5) 0% | (0/5) 0% | ||
| Walking cast | 6 weeks | (1/1) 100% | (1/1) 100% | ||||
| Plaster cast | 2 weeks | (1/1) 100% | (1/1) 100% | ||||
| Klos et al. 201117 | Anti-inflammatories, rest, physical therapy, brace | 8 weeks | (1/1) 100% | (1/1) 100% | (1/1) 100% | ||
| Siegel et al. 200819 | Lateral malleolar cup | 6 months | (0/1) 0% | (0/1) 0% | (0/1) 0% | (0/1) 0% |
Stover et al.20 described 16 patients, who were treated non-operatively in five procedures. Different rates of recurrent dislocation were reported: tape in neutral position 4 weeks 100% (4/4), tape in neutral position 6 weeks 40% (2/5), non-weight bearing cast 6 weeks 0% (0/5), walking cast 6 weeks 100% (1/1) and plaster cast 6 weeks 100% (1/1). Patients treated with a non-weight bearing cast for six weeks are associated with low occurrence of pain and no patients reported inability to return to former activities or sensation of instability. Patients treated with tape experienced a higher rate of pain, inability to return to former activities and sensation of instability. In 37.5% (6/16) of the cases late surgical repair was performed. Klos et al.17 described treating one patient with physical therapy, rest, anti-inflammatories and brace, but late surgical repair was required due to existence of pain and sensation of instability. Siegel et al.19 reported good results using a lateral malleolar cup as a non-operative treatment for a 12-year old athlete.
When all results are combined a success rate of 40% (12/30) is obtained when tape for at least 3 weeks was used (Table 3). A plaster cast for at least 4 weeks resulted in successful treatment in 62% (8/13), a plaster cast for at least 6 weeks resulted in success in 83% (5/6) of the cases.
Table 3.
Succes rates (no-recurrent dislocation) for different treatments.
| Intervention characteristics | duration of treatment | No recurrent dislocation |
|---|---|---|
| Tape | ≥3 weeks | (12/30) 40% |
| Plaster cast | ≥4 weeks | (8/13) 62% |
| Plaster cast | ≥6 weeks | (5/6) 83% |
3.4. Risk of bias assessment
All studies scored a high or unclear risk of bias in four of six domains. A low risk of bias was seen in two studies addressing incomplete outcome data or selective reporting. For this reason, the methodological quality of all included studies was considered low. The quality assessment is summarized in Table 4.
Table 4.
Cochrane Collaboration's tool for assessing risk of bias.
| Study | Random sequence generation | Allocation concealment | Blinding of participants and personnel | Blinding of outcome assessment | Incomplete outcome data | Selective reporting |
|---|---|---|---|---|---|---|
| Eckert et al. 197615 | – | – | – | – | – | Unclear |
| Escalas et al. 198016 | – | – | – | – | – | – |
| McLennan et al. 198018 | – | – | – | – | Unclear | – |
| Stover et al. 196220 | unclear | Unclear | – | – | – | + |
| Klos et al. 201117 | – | – | – | – | + | – |
| Siegel et al. 200819 | – | – | – | – | – | – |
– is high risk of bias, + is low risk of bias, unclear is unclear risk of bias.
4. Discussion
Operative treatment of peroneal tendon dislocation is advocated by many authors.3,11,13 Nevertheless, some patients are not eligible or refuse to undergo surgery. Therefore, it is important to obtain more knowledge about the clinical outcome of non-surgical interventions. This systematic review suggests that a 4–6 week below knee plaster cast prevents recurrent dislocation in 62%–83% of the patients (Table 3).
Many non-operative therapies have been described with varying effects in the prevention of recurrent dislocation. Taping, compressive bandage and early mobilization are associated with a high rate of recurrent dislocation.16,18 Peroneal tendon dislocation treated with tape for at least 3 weeks obtains a 40% success. After initial non-operative treatment, some patients with a recurrent dislocation underwent late surgical repair. The lesion was only repaired surgically if a dislocation re-occurred in combination with pain, instability or the inability to return to former activities.
The treatment of peroneal tendon dislocation has been described by many authors.3,12,13 Some authors advocate surgical repair because failure rates for non-operative therapy are considered to be high; 50–76%.10 However, the association with the ineffectiveness of non-operative treatment is mainly based on three articles.15, 16, 17 As shown in the risk of bias assessment these studies are considered high risk of bias and the methodological quality of these studies is questionable.
A recent review reported good results of surgery, with a redislocation rate of 2% and patient's satisfaction rate of 90%.10 However, some studies mentioned post-surgical complications including decrease of activity, swelling and nerve entrapment.21,22 None of these complications were reported in the included studies when a below knee plaster cast was used for at least 4 weeks.
This study had several limitations. Due to the nature of the included study designs, there was a high risk of incomplete data outcome, selective reporting and the numbers of included patients were too small to obtain sufficient, robust evidence. Unfortunately, no higher-level evidence studies were available. Second, between and within studies patients received different treatments. Therefore, no statistical analysis was performed. Third, all studies failed to report their definition for peroneal tendon dislocation and in most studies the time between trauma and treatment was unclear. The severity of dislocation might have varied across patients, therefore therapy results were likely to be misinterpreted. Previous studies suggested that non-operative treatment is most effective in the acute phase. Unfortunately, due to the uncertainty of accurate time of treatment it was not possible to provide a good discrimination between an acute or chronic dislocation.10 Time to follow-up was mentioned in three studies.17, 18, 19 The reported time to follow-up in these studies was only 6–18 months. Therefore it is unknown whether a re-dislocation occurred or surgical repair was performed after these 6–18 months.
Despite these limitations, this study summarized all present evidence of non-operative treatment for peroneal tendon dislocation. If non-operative treatment is preferred, a 6 week plaster cast should be considered.
In order to make an evidence based statement concerning the effectiveness of non-operative treatment new studies must consider providing data suitable for comparison. Future studies should report data including, age, gender, nature of injury, time to injury, time to treatment, intervention characteristics, total duration of treatment, number of recurrent dislocations, pain score, inability to return to former activities, sensation of instability, number of late surgical repair and total follow-up time.
Although the quality of the reported studies is at high risk of bias, this review gives a clarification of all published studies concerning non-operative treatment and an insight in its effectiveness. A below the knee plaster cast for 4–6 weeks seems an effective non-operative treatment in 62% (8/16) to 83% (5/6) of the patients and therefore a possible sufficient alternative for surgery.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Conflicts of interest
The authors declare that they have no conflict of interest.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jor.2019.08.031.
Appendix.
Embase.com
(('peroneus muscle'/de AND ('tendon'/de OR ‘tendon injury'/de OR ‘tendon surgery'/de)) OR (Perone* NEAR/6 (tendon*)):ab,ti) AND (dislocation/de OR subluxation/de OR injury/de OR ‘tendon injury'/de OR ‘ankle instability'/de OR ‘conservative treatment'/de OR ‘bandages and dressings'/exp OR ‘tendon rupture'/de OR (dislocat* OR luxation* OR sublux* OR instab* OR injur* OR retinacul* OR ruptur* OR tear* OR lacerat* OR trauma* OR displace* OR conservativ* OR traditiona*l OR bandage* OR tape OR taping OR plaster* OR cast OR therap* OR treat* OR ‘bed rest’ OR nonsurg* OR nonoperat* OR (non NEXT/1 (surg* OR operat*))):ab,ti) NOT ([animals]/lim NOT [humans]/lim).
Medline ovid
((Perone* ADJ6 (tendon*)).ab,ti.) AND (dislocations/OR “Wounds and Injuries"/OR “Tendon Injuries"/OR exp “Bandages"/OR (dislocat* OR luxation* OR sublux* OR instab* OR injur* OR retinacul* OR ruptur* OR tear* OR lacerat* OR trauma* OR displace* OR conservativ* OR traditiona*l OR bandage* OR tape OR taping OR plaster* OR cast OR therap* OR treat* OR “bed rest” OR nonsurg* OR nonoperat* OR (non ADJ (surg* OR operat*))).ab,ti.) NOT (exp animals/NOT humans/)
Cinahl ebsco
((MH “Peroneus Longus Muscles” AND (MH tendons OR MH “Tendon Injuries+")) OR MH “Peroneal Tendons” OR (Perone* N5 (tendon*))) AND (MH dislocations OR MH “Wounds and Injuries” OR MH “Tendon Injuries” OR MH “Bandages and Dressings+" OR (dislocat* OR luxation* OR sublux* OR instab* OR injur* OR retinacul* OR ruptur* OR tear* OR lacerat* OR trauma* OR displace* OR conservativ* OR traditiona*l OR bandage* OR tape OR taping OR plaster* OR cast OR therap* OR treat* OR “bed rest” OR nonsurg* OR nonoperat* OR (non N1 (surg* OR operat*)))) NOT (MH animals + NOT MH humans+).
Cochrane
((Perone* NEAR/6 (tendon*)):ab,ti) AND ((dislocat* OR luxation* OR sublux* OR instab* OR injur* OR retinacul* OR ruptur* OR tear* OR lacerat* OR trauma* OR displace* OR conservativ* OR traditiona*l OR bandage* OR tape OR taping OR plaster* OR cast OR therap* OR treat* OR ‘bed rest’ OR nonsurg* OR nonoperat* OR (non NEXT/1 (surg* OR operat*))):ab,ti).
Web-of-science
TS=(((Perone* NEAR/5 (tendon*))) AND ((dislocat* OR luxation* OR sublux* OR instab* OR injur* OR retinacul* OR ruptur* OR tear* OR lacerat* OR trauma* OR displace* OR conservativ* OR traditiona*l OR bandage* OR tape OR taping OR plaster* OR cast OR therap* OR treat* OR “bed rest")) NOT ((animal* OR horse* OR equus* OR equine* OR rat OR rats OR mouse OR mice OR murine OR rabbit* OR dog OR dogs OR canine OR cat OR cats OR feline OR swine OR porcine OR nonsurg* OR nonoperat* OR (non NEAR/1 (surg* OR operat*))) NOT (human* OR patient*)))
Google scholar
“Peroneal tendon|tendons” dislocation|dislocated|luxation|subluxation|subluxing|displacement|conservative|conservatively|traditional|bandages|tape|taping|plaster|cast|"bed rest"|nonsurgical|nonoperative.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
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