Abstract
Background
Peroneal tendons dislocation is an infrequent and misdiagnosed pathology. The aim of this study was to establish the relevance of the anatomic characteristics of fibular groove and the superior peroneal retinaculum, and its relationship with peroneal tendon stability. Methods: The present study was conducted on 14 lower extremities of fresh defrosted cadavers. Anatomical parameters of the fibula, peroneal tendons, superior peroneal retinaculum and minimal deep required to achieve peroneal tendon stability in the peroneal groove were done. Results: A statistically significant difference in the minimum depth required to achieve peroneal sulcus stability was found between groups with superior peroneal retinaculum type I and V (p = 0.015). Conclusions: Our findings provide novel anatomical and morphometric evidence supporting the relevance of superior peroneal retinaculum morphology, particularly type I, in promoting peroneal tendon groove stability.
Level of Evidence
IV
1
Introduction
Peroneal tendons (PTs) dislocation or subluxation is a relatively infrequent pathology which is often misdiagnosed as an ankle sprain. It affects mainly young adults hindering daily or sports activities , . The findings are subtle and are usually masked by swelling, ecchymosis, instability, lateral hindfoot and ankle pain ,, . An inadequate groove, laxity or congenital absence of the superior peroneal retinaculum (SPR) may increase the risk of subluxation . It often occurs because of a single traumatic event of forced or sudden dorsiflexion of the ankle leading the peroneus longus (PL) and brevis (PB) tendons eccentrically contract as the ankle flexes, generating anterolateral force against SPR and its traumatic rupture or avulsion, producing transient lateral dislocation ,,, . Difficulty in diagnosing or inadequate initial treatment may produce recurrent subluxation or chronic dislocation of the tendons, leading to additional PTs injury , .
Fibular groove (FG) has been described as possible etiological factor which contributes to subluxation of the PTs. Shallow FG could ease PTs tears and dislocation , ; therefore, as mentioned by Yokoe et al., correct assessment of FG morphology is of great importance to foot and ankle surgeons . Mabit et al. found three types of morphological variations: concave, flat and convex . Wrapping around the lateral malleolus the PTs pass from the leg to the foot, lying in a fibro-osseous tunnel, formed by the bone and the SPR, a single sheath that extends proximally to the malleolus tip. The anterolateral aspect of this tunnel has a dense fibrocartilaginous rim, prolonged into a ridge to which the SPR is attached ,,,, .
Other structures have been found as additional content within the superior peroneal tunnel: Muscle fibers of PB, ruptured PB tendon, tendon or muscle belly of peroneus quartus, double PL tendon and accessory peroneal nerve. It is expected that the PB muscle would end an average of 1.6–2.0 cm above the distal tip of the fibula. As described by Mirmiran et al., a low-lying PB (LLPB) muscle is an extension of the muscle belly within the FG. In 1997, LLPB was described in 11/12 subjects in dorsiflexion and in 7/12 subjects in plantar flexion ,,, . LLPB was associated with 29.03 % tendon subluxation. .
Patients with acute PTs subluxation often have poor clinical outcomes after conservative treatment, with failure rates approximating 50–76 % , . Surgical treatment is advised in painful chronic dislocations when the tendons slip in and out of the FG, providing positive clinical results , . More than 20 surgical techniques have been described. The procedures attempt to restore the superior peroneal tunnel: repairing or replacement of the SPR, groove deepening, bony procedures or rerouting procedures , . In 2021 a study of patients with recurrent PTs dislocation, who underwent retinaculum repair without FG deepening procedure considered the reattachment of SPR followed by proper rehabilitation is enough . The aim of the present study was to establish the relevance of the anatomic characteristics of the FG and the SPR, and its relationship with the PTs luxation. We couldn’t find in the literature any other study which looked to relate these characteristics with PTs stabilization into FG. We hypothesize that groove deepening is needed to provide a more stable structure and decrease new dislocation.
2
Materials and methods
The present study was conducted on 14 lower extremities (N = 14) of fresh defrosted cadavers, between 10/2024 and 12/2024. The cadaveric lower extremities were obtained according to the body donation program of our institution as stated by the current local laws. Exclusion criteria included deformity or previous surgery. We measured the length of the fibula and its wide 1 cm proximal to the malleolar tip; the length, wide, and depth of the malleolar groove; the angle between PTs and the fibular axis; the SPR length and wide; the PB and PL tendon length, wide and thick; the ridge depth; and the relationship between the tibial plafond and the malleolar tip ( Tables 1–2 ).
Table 1
Anatomic characteristics of fibular groove and peroneal tendons.
| # | Side | Gender | Age | FL | FW | SPRL | SPRW | SPRT | PBW | PBT | PLW | PLT | PBA | PLA | PBD | PLD | GW | GL | RH | GT |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | Right | Female | 86 | 35,2 | 16,6 | 22 | 33,2 | I | 12,1 | 1 | 6,2 | 1,7 | 5 | 7 | 12,3 | 14,3 | 9,3 | 22,9 | 2,1 | Flat |
| 2 | Left | Female | 86 | 34,8 | 18,9 | 20,9 | 21,8 | I | 12,7 | 0,7 | 5,9 | 1,8 | 5 | 7 | 14,5 | 14 | 11,2 | 20,9 | 2,6 | Flat |
| 3 | Left | Male | 81 | 39,8 | 19,9 | 34,9 | 14,8 | V | 8,7 | 1,8 | 8,5 | 2,2 | 8 | 9 | 11,7 | 15,6 | 13,3 | 22,1 | 3,7 | Flat |
| 4 | Right | Male | 81 | 39,2 | 22,8 | 32,7 | 24,8 | I | 7,5 | 1,3 | 7,6 | 2,3 | 6 | 7 | 9,5 | 14,1 | 9,9 | 23,6 | 1,9 | Flat |
| 5 | Right | Female | 80 | 34,6 | 19,5 | 28,2 | 19,7 | I | 10,4 | 1,2 | 6,9 | 2,3 | 10 | 5 | 14,7 | 17,6 | 8,7 | 20,7 | 2,6 | Concave |
| 6 | Left | Female | 94 | 31,5 | 19,8 | 38,2 | 27,5 | I | 7,4 | 1,5 | 6,8 | 2,7 | 7 | 4 | 16,9 | 18,9 | 8,8 | 24,8 | 1,5 | Flat |
| 7 | Right | Female | 97 | 36,1 | 16,7 | 26,9 | 22,8 | I | 7,5 | 1,7 | 7,4 | 2,6 | 5 | 8 | 15,1 | 16,1 | 7,8 | 21,9 | 2,1 | Concave |
| 8 | Left | Male | 79 | 36,9 | 19,2 | 35,8 | 23,5 | I | 8,6 | 1,2 | 5,7 | 2,5 | 4 | 3 | 17,5 | 20,8 | 6,2 | 21,3 | 3 | Flat |
| 9 | Left | Male | 95 | 36,8 | 26,1 | 28,6 | 22,3 | V | 11,1 | 1,4 | 7,7 | 2,6 | 6 | 3 | 14,6 | 20,5 | 11,4 | 33,6 | 2,7 | Flat |
| 10 | Right | Male | 95 | 37,1 | 18,7 | 28,4 | 22,5 | V | 9,5 | 0,8 | 8,5 | 2,4 | 3 | 7 | 13,7 | 14,3 | 10,8 | 23,3 | 2,7 | Concave |
| 11 | Right | Female | SD | ND | 20,8 | 36,5 | 29,3 | I | 7,1 | 2 | 7,6 | 0,7 | 7 | 6 | 15,4 | 19,1 | 7,4 | 24,7 | 3 | Concave |
| 12 | Left | Female | SD | ND | 18,8 | 32,3 | 27,3 | I | 7,8 | 0,8 | 6,6 | 2,2 | 5 | 6 | 6,6 | 13,7 | 7,7 | 24,4 | 5,5 | Concave |
| 13 | Right | Female | 94 | 35,55 | 18,8 | 33,1 | 24,9 | I | 9,4 | 1,8 | 6,3 | 2,5 | 7 | 8 | 19,9 | 16,3 | 11,1 | 24,3 | 3,4 | Concave |
| 14 | Left | Female | 94 | 34,95 | 14,4 | 34,8 | 20,1 | I | 6,1 | 2,3 | 8,6 | 1,4 | 8 | 7 | 13,1 | 11,1 | 7,7 | 24,3 | 4 | Flat |
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