Introduction:

Although dislocation of the peroneal tendons (PT's) in association with calcaneal fractures has been described over 25 years ago, it frequently passes unrecognised by radiologists and orthopaedic surgeons. This retrospective study aims to determine the prevalence of PT dislocation in association with calcaneal fractures at a single institution and describe systematic steps to avoid missed diagnosis at each stage of management.

Background. This study analyzes position of the peroneal tendons and status of the superior peroneal retinaculum (SPR) whenever a lateral malleolar bony flake fracture occurs. Methods. Twenty-four patients had a lateral malleolar bony fleck on anteroposterior ankle radiographs, either in isolation or associated with other hindfoot injuries. We studied size of the bony flecks, presence or absence of peroneal tendon dislocation and pathoanatomy on CT scans. Results. In 11 patients, a small bony fleck lies within the superior peroneal retinaculum and contiguous periosteum, which are stripped off the lateral fibula (Class II lesions). Tendons dislocate into the subperiosteal pouch thus formed, resembling Class I lesions without associated bony avulsion. Treatment for Class II is same as for Class I injuries. In 8 patients with big bony fleck, tendons dislocate into the fracture site and SPR is intact (Class III lesions). Surgical approach for tendon relocation and bone fixation differs. In particular, the intact attachment of the SPR on the bony fleck must not be incised. The healing process of neglected Class III lesions resembles a groove deepening procedure, representing an attempt to form a stable platform for the dislocated tendons. A neglected Class II lesion resembles a neglected Class I lesion. In Class IV lesions, observed in 5 patients with 2-part calcaneal fracture/dislocation, SPR remains intact and peroneal tendons are not dislocated. The invariably large fleck results from the displacing lateral calcaneal fragment abutting against the fibula, whereas the dislocating tendons cause the bony avulsions in Classes II and III. Conclusions. Due to pathoanatomical differences, surgical approach and natural history of neglected lesions differ depending on size of the bony fleck. The SPR must not be incised in case of big Class III flecks. Beware of false negatives when probing the peroneal tendons intra-operatively in Class III and IV lesions

Recurrent dislocation of peroneal tendons is an uncommon presentation following ankle injuries. It usually follows an inversion injury to the ankle, most commonly seen in skiing, however it has also been described in many other sporting activities. X rays appear normal, and patients usually get treated as ankle sprain. The diagnosis, usually delayed is a clinical one, patients usually describe ankle instability and sudden painful snapping or popping of the subluxating peroneal tendons. This makes it difficult for them to participate in any sporting activities and is a source of continous discomfort while walking. Examination may show tender peroneal tendons and demonstration of subluxing tendons is facilitated by eversion against resistance or manually by thumb pressure. The common pathology is tear of the peroneal retinaculum and striping of periosteum from the anterior attachment to the lateral maleolus. We describe 11 cases of recurrent dislocation of peroneal tendons from February 1999 to October 2004. They all suffered trauma related dislocation of peroneal tendons, causing recurrent peroneal tendon dislocation. All procedures were performed by a single consultant. Procedure involves soft tissue anatomic reconstruction of the peroneal retinaculum. There were 9 males and 2 females, mean age was 30.1 years (range 15 to 58 years). All patients were treated initially with rest followed by period of physiotherapy to no benefit. All complained of ankle instability with pain associated with tendon dislocation even while walking. The mean duration from time of injury to surgery was 10 months (range 2 to 45 months). We performed clinical assessment, ankle scoring, SF 36 version2 scoring and assessed patient satisfaction with the procedure. At the latest follow up of 6 months to 6 years all patients were extremely satisfied with the procedure. There was no recurrence of dislocation. All patients were back to their normal daily activities and sports within 6 months of surgery. One patient complained of occasional mild pain over the tendon. One patient reported mild paraesthesiae in distribution of sural nerve, which recovered over 3 months. On clinical assessment the tendon was stable in all patients with full ROM and strength in the affected ankle when compared to normal side. The mean ankle score increased from 62 pre-op (range 22 to 89) to 96 post-operative (range 90 to 100). Mean SF 36 scores increased from PCS of 41 and MCS of 53 pre-op to a PCS of 57 and MCS of 60 post-op. In the past procedures have been described for treatment of recurrent dislocation of peroneal tendons. We report the results of a procedure previously described and published by the senior author ( ‘The Foot’: 2003 ). This is an anatomic procedure for repair of torn peroneal retinaculum and double breasting of redundant periosteum. Our latest follow up of 6 months to 6 years shows excellent results with no recurrence and no limitation of ankle movement or sporting activities