Pediatric ankle injuries are common; ankle epiphyseal fractures are also common in children. But isolated distal epiphyseal fibular fractures of the distal fibula are clinically rare. We describe one unusual case of an adolescent with a completely displaced Salter-Harris type II distal fibular epiphyseal fracture. The attempt of closed reduction failed, and the patient required open reduction and internal fixation. The localized periosteum and the superior peroneal retinaculum were avulsed from the distal fibular metaphysis, with the peroneal tendons underneath exposed but no obvious subluxation. To the best of our knowledge, this combination of injuries has not been previously reported.

OBJECTIVE: While the incidence of peroneal tendon dislocation (PTD) is relatively low, it is frequently underdiagnosed in clinical practice, and the misdiagnosis or improper treatment of this condition may lead to a decline in patients\' quality of life. Currently, the surgical treatment options for PTD mainly include open and arthroscopic surgery. However, in order to evaluate the advantages and disadvantages of these two surgical approaches, further comparative research is needed. Therefore, the aim of this study is to investigate the early clinical outcomes of arthroscopic and open surgery in the treatment of Ogden type 1-2 PTD.
METHODS: We conducted a comprehensive analysis of 46 patients diagnosed with PTD who underwent surgery at our institution between January 2017 and January 2023. The patients were divided into two groups: the open surgery group, consisting of 26 cases, and the arthroscopic surgery group, consisting of 20 cases. To compare the effectiveness of the surgical approach, we evaluated several parameters, including the integrity of the superior peroneal retinaculum on MRI images, functional scores, pain interference scores, and ankle eversion muscle strength. These assessments are conducted respectively before the surgery, 1 month after the surgery, 3 months after the surgery, and at the final follow-up for each group of patients (at least 6 months post-surgery). Demographics and intergroup comparisons of the two groups of data were analyzed by t-test or the Mann-Whitney U test. Intragroup comparisons of the two groups of data were analyzed by one-way analysis of variance (ANOVA) or the Kruskal-Wallis test, followed by post hoc multiple comparisons.
RESULTS: In the intragroup comparisons, both the arthroscopic surgery and the open surgery group demonstrated significant improvement in functional scores, pain interference scores, muscle strength, and MRI findings at the final follow-up postoperatively (p < 0.01). However, the open surgery group exhibited significant improvements in these outcomes at the final follow-up, while the arthroscopic surgery group showed significant improvement at 3 months postoperatively. In intergroup comparisons, the arthroscopic surgery group outperformed the open surgery group in functional scores, pain interference scores, and muscle strength 3 months after the surgery, with statistically significant differences (p < 0.01).
CONCLUSIONS: Arthroscopic surgery offers advantages in early clinical outcomes, such as pain relief, function, and muscle strength improvement. However, over time, both approaches provide similar results regarding effectiveness.

To evaluate the clinical results of modified peroneal sulcus deepening combined with superior peroneal retinaculum repair in peroneal tendon subluxation treatment.
From 2016 to 2020, 18 patients with peroneal tendon subluxation were diagnosed and treated; all patients underwent modified peroneal sulcus deepening combined with superior peroneal retinaculum repair. The visual analogue scale (VAS) score, American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS-AH) score, and subjective patient satisfaction were evaluated before surgery and during follow-up.
The operative time was 66.44 ± 5.22 min. All patients\' surgical incisions showed grade A healing, and there were no complications. All patients were followed up for 24-48 months; no patients were lost to follow-up. At the last follow-up, the VAS and AOFAS-AH scores were significantly improved compared with those pre-operatively (P < 0.05). There was no significant difference in the activity of the 18 patients between pre- and post-operatively, and all patients recovered their normal gait before injury.
Modified fibular groove deepening combined with superior peroneal retinaculum repair for treating peroneal tendon subluxation may be a simple operation with minimal trauma, rapid recovery, and good clinical efficacy.

UNASSIGNED: Neglected peroneal tendon dislocation with iatrogenic etiology has been rarely reported in the literature and its management has not been fully understood to date.
UNASSIGNED: We present a case of a 25-year-old male who presented with pain over the posterolateral aspect of his left ankle which was diagnosed to be a case of neglected peroneal tendon dislocation of iatrogenic etiology. Peroneal groove deepening with superior retinaculum repair was done in the patient along with loose body removal and osteophyte excision. Subsequent fibrosis augmented with the deepening of the groove maintained peroneal tendon position in the retromalleolar groove. On post-operative follow-up, the patient was completely satisfied with relief of pain and no complications. He also regained full range of motion and could walk without support.
UNASSIGNED: Surgical intervention of fibular groove deepening with superior peroneal retinaculum reconstruction results in an excellent outcome for neglected peroneal tendon dislocation.

Peroneal subluxation is a rare but debilitating pathology that can be the result of a superior peroneal retinaculum tear or intrasheath laxity. On clinical examination of both cases, the pathology is observed when the ankle is circumducted in eversion and dorsiflexion. With a superior peroneal retinaculum tear, the tendons dislocate from the peroneal groove, whereas with intrasheath laxity the tendons remain in the groove. In the present case series, peroneal stabilization was performed for both superior peroneal retinaculum tear and intrasheath laxity. With our technique, the fibro-osseous connections of the peroneal tendon sheath are detached from the distal one third of the fibula. Drill holes are made through the fibula for suture to be passed through and the peroneal tendon sheath is reattached to the fibula through horizontal mattress sutures via pants over vest technique to restore tension to the sheath. A total of 5 patients underwent peroneal stabilization, 100% (5/5) of which had preoperative pain with palpation along the peroneal tendons and a palpable click with range of motion of the ankle joint. Postoperatively, 100% (5/5) of the patients were fully weight-bearing, compared to 60% (3/5) preoperatively. No patients had residual subluxation of the peroneal tendons postoperatively or a need for revisional surgery. Residual peroneal tendonitis was present in 20% (1/5) of patients and sural neuritis occurred in 20% (1/5) of patients. The peroneal tendons are physiologically tightened within the peroneal tendon sheath to mitigate the pathologic subluxation, without sacrificing tendons for transfer or using allograft material.Clinical Level of Evidence: Therapeutic, Case Series, Level 4.

Chronic lateral ankle instability is a prevalent condition, and it is commonly associated with other foot and ankle injuries. Among the associated injuries, peroneal tendon pathologies and anterolateral ankle impingement are frequently encountered. In this report, a case of concomitant chronic lateral ankle instability and dislocation of the peroneal tendons is described. While this combination of injuries is not uncommon, the method of treatment entailed arthroscopic repair of the anterior talofibular ligament and endoscopic repair of the superior peroneal retinaculum, procedures that eliminated the anterior drawer instability that had been present, and the patient remained symptom free after 24 months of follow-up.

OBJECTIVE: The purpose of the present anatomical study was to define the exact morphology of the posterior fibulotalocalcaneal ligament complex (PFTCLC), both for a better orientation and understanding of the anatomy, especially during hindfoot endoscopy.
METHODS: Twenty-three fresh frozen specimens were dissected in order to clarify the morphology of the PFTCLC.
RESULTS: In all specimens, the ligament originated from the posteromedial border of the lateral malleolus between the posterior tibiofibular ligament (superior border) and the calcaneofibular ligament (CFL), (inferior border). This origin functions as the floor for the peroneal tendon sheath. The origin of the PFTCLC can be subdivided into two parts, a superior and inferior part. The superior part forms an aponeurosis with the superior peroneal retinaculum and the lateral septum of the Achilles tendon. From this structure, two independent laminae can be identified. The inferior part of the origin has no role in the aponeurosis and ligamentous fibres run obliquely to insert in the lateral surface of the calcaneus, in the same orientation as the CFL, but slightly more posterior, which was a consistent finding in all examined specimens. The PFTCLC is maximally tensed with ankle dorsiflexion and is located within the fascia of the deep posterior compartment of the leg.
CONCLUSIONS: The PFTCLC is part of the normal anatomy of the hindfoot and therefore should be routinely recognized and partly released to achieve access to the posterior ankle anatomical pathology, relevant for hindfoot endoscopy. The origin of the ligament complex forms the floor for the peroneal tendon sheath. The superior part of the origin plays a role in the formation of an aponeurosis with the superior peroneal retinaculum and the lateral septum of the Achilles tendon.

The present study investigated the relationship between type of calcaneal fractures and subluxation or dislocation of peroneal tendon. Also, we investigated clinical outcomes of patients with both calcaneal fractures and dislocations or subluxations of peroneal tendons in early surgical treatments (at the time of surgery for calcaneal fractures) and delayed surgical treatment (at the time of surgery for calcaneal plate removal) for dislocations or subluxations of peroneal tendons. We included 151 patients with calcaneal fractures who were followed for ≥2 years after surgery. Among them, 21 cases (13.9%) required reduction for peroneal tendon subluxation or dislocation. Reductions of peroneal tendons were performed at the time of surgery for calcaneal fractures in 11 cases, whereas the other 10 cases were performed during surgery for calcaneal implant removal. As classified by Essex-Lopresti, 94 cases (62.3%) were joint depression type and 17 (18.1%) were accompanied by dislocations or subluxations of peroneal tendons, whereas 57 (37.7%) were tongue type and 4 (7.0%) were accompanied by dislocations or subluxations of peroneal tendons. As classified by the Sanders system, 96 cases (63.6%) were Sanders A fracture lines, and 18 (18.8%) were accompanied by dislocations or subluxations of peroneal tendons. In 55 cases (36.4%) without Sanders A fracture lines, 3 (5.5%) were accompanied by dislocations or subluxations of peroneal tendons. In conclusion, calcaneal fractures with peroneal tendon dislocations are more common in joint depression type and Sander A type. Also, after a ≥2-year follow-up period, there were no significant differences in visual analog scale or foot and ankle outcome score whether reduction of peroneal tendons was done with reduction of fracture or removal of implant of calcaneus.

During extensile lateral approach to the calcaneus, in order to see all fractured fragments and subtalar joint, all soft tissues including insertion site of superior peroneal retinaculum (SPR) on the calcaneus should be released. The aim of this study was to evaluate the probability of peroneal tendon dislocation by releasing all soft tissues attached to the calcaneus. In 10 fresh cadavers, after standard extensile lateral approach to the calcaneus in right side, all soft tissues attached to the lateral wall of the calcaneus were excised. In the left side of each cadaver, all soft tissues inserted to the superior border of calcaneal tuberosity in addition to the lateral wall of the calcaneus were cut out. Probable anterior dislocation of peroneal tendons in the retromalleolar groove was assessed by placing a clamp into the peroneal tendon sheath from distal to proximal and advancing it to the retromalleolar groove. Also by careful dissection, any instability of peroneal tendons was visualized. Not any anterior dislocation of peroneal tendons to the lateral malleolus tip was seen in any stage of the procedure. Insertions of the SPR to the fascia of the deep posterior compartment of the leg and the Achilles tendon sheath are the main soft tissue stabilizer of the peroneal tendons in the retromalleolar groove. So resection of the insertion site of the SPR to the calcaneus might not result in the peroneal tendon instabilities.

BACKGROUND: This study was conducted to investigate characteristics, attachments and morphometric parameters of the superior peroneal retinaculum (SPR).
METHODS: Morphology and morphometric details including width, length, thickness and angle of alignment of SPR in 109 embalmed cadaveric legs were investigated. The occurrence of peroneal tendon tear was also noted.
RESULTS: Most of SPR originated from the fibrocartilaginous ridge of the lateral malleolus. The SPR might be a single band or split into proximal and distal bands inserted on the posterior intermuscular septum and lateral wall of calcaneus, respectively. Based on the characteristics and insertion patterns, the SPR could be divided into 3 types: type I (double band with subtype Ia and Ib), type II (single band) and type III (single band) with the prevalence of 56.88% (12.84%, 44.04%), 1.83%, and 41.28%, respectively. The average coordinate (X, Y axis) of the midpoint of width at origin measured from the tip of fibula in all types was 7.26±3.15 and 10.45±4.52 mm. The average coordinate of the midpoint at insertion on the posterior intermuscular septum was 24.06±4.94 and 13.35±5.18, and those inserted on the lateral wall of calcaneus was 21.45±7.88 and 13.59±6.73 mm. Prevalence of peroneus brevis (PB) tendon tear was 12.84% (14 cases) and was associated with SPR type Ib with statistical significance.
CONCLUSIONS: Precise information of the characteristics, morphometric data and coordinates of attachment sites of SPR are essential for surgical procedures and reconstruction.