Raikin Steven M
Department of Orthopaedic Surgery Rothman Institute Thomas Jefferson University Hospital 925 Chestnut Street Philadelphia, PA 19107, USA.
J Bone Joint Surg Am. 2009 Mar 1;91 Suppl 2 Pt 1:146-55. doi: 10.2106/JBJS.H.01356.
Dislocation or subluxation of the peroneal tendons out of the peroneal groove under a torn or avulsed superior peroneal retinaculum has been well described. We identified a new subgroup of patients with intrasheath subluxation of these tendons within the peroneal groove and with an otherwise intact retinaculum.
The cases of fifty-seven patients with painful snapping of the peroneal tendons posterior to the fibula were reviewed. Of these, forty-three had tendons that could be reproducibly subluxated out of the groove with a dorsiflexion-eversion maneuver of the ankle. Fourteen patients who could not subluxate the tendons out of the groove underwent a dynamic ultrasound examination of the tendons. While the same dorsiflexion and eversion maneuver was being performed, the tendons were seen to switch their relative positions (the peroneus longus came to lie deep to the peroneus brevis tendon) with a reproducible painful click. All fourteen patients underwent a peroneal groove-deepening procedure with retinacular reefing. Intraoperatively, thirteen patients were found to have a convex peroneal groove and all fourteen had an intact peroneal retinaculum. All patients subsequently underwent a follow-up dynamic ultrasound examination and an American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score evaluation at a minimum of twenty-four months after surgery.
All fourteen patients were female, with an average age of thirty-five years. Two subtypes of intrasheath subluxation were found. Type A (ten patients) involved intact tendons with relative switching of their anatomic alignment. Type B (four patients) involved a longitudinal split within the peroneus brevis tendon through which the longus tendon subluxated. Intraoperative confirmation of the ultrasound findings was 100%. At an average follow-up interval of thirty-three months, the average AOFAS score had improved from 61 points preoperatively to 93 points, and the average score on the 10-cm visual analog pain scale had improved from 6.8 to 1.2. Follow-up ultrasound evaluation revealed healed tendons without persistent subluxation in thirteen patients. Nine patients rated the result as excellent, four rated it as good, and one rated it as fair.
Patients with retrofibular pain and clicking of the peroneal tendons may not have demonstrable subluxation on physical examination and may have an intact superior peroneal retinaculum. They may have an intrasheath subluxation of the peroneal tendons, which can be confirmed with use of a dynamic ultrasound. Surgical repair of tendon tears combined with a peroneal groove-deepening procedure with retinacular reefing is a reproducibly effective procedure for this condition.
腓骨肌腱在腓骨上支持带撕裂或撕脱时脱位或半脱位至腓骨沟外的情况已有详细描述。我们发现了一组新的患者亚群，其腓骨肌腱在腓骨沟内腱鞘内半脱位，而腓骨上支持带其他部分完整。
回顾了57例腓骨后方腓骨肌腱疼痛弹响患者的病例。其中，43例患者的肌腱在踝关节背屈-外翻动作时可重复出现脱位至沟外的情况。14例无法使肌腱脱位至沟外的患者接受了肌腱动态超声检查。在进行相同的背屈和外翻动作时，可见肌腱相对位置发生改变（腓骨长肌腱位于腓骨短肌腱深面），并伴有可重复出现的疼痛弹响。所有14例患者均接受了腓骨沟加深及支持带折叠手术。术中发现13例患者的腓骨沟呈凸形，所有14例患者的腓骨上支持带均完整。所有患者术后至少24个月均接受了随访动态超声检查及美国矫形足踝协会（AOFAS）踝-后足评分评估。
所有14例患者均为女性，平均年龄35岁。发现腱鞘内半脱位有两种亚型。A型（10例患者）涉及肌腱完整但解剖排列相对改变。B型（4例患者）涉及腓骨短肌腱纵向裂开，长肌腱由此半脱位。超声检查结果的术中确认率为100%。平均随访33个月时，AOFAS平均评分从术前的61分提高到93分，10厘米视觉模拟疼痛量表平均评分从6.8分提高到1.2分。随访超声评估显示13例患者肌腱愈合且无持续性半脱位。9例患者对结果评价为优，4例评价为良，1例评价为可。
腓骨后方疼痛且腓骨肌腱有弹响的患者在体格检查时可能无明显半脱位，且腓骨上支持带可能完整。他们可能存在腓骨肌腱腱鞘内半脱位，这可通过动态超声检查确诊。肌腱撕裂的手术修复联合腓骨沟加深及支持带折叠手术对此病症是一种可重复的有效治疗方法。
