ORIGINAL ARTICLE

Calcaneofibular Ligament Transfer for Recurrent Peroneal

Tendon Subluxation in Pediatric and Young Adult Patients
Derek S. Stenquist, BA,* Tyler A. Gonzalez, MD, MBA,w Frances A. Tepolt, MD,z
Dennis E. Kramer, MD,*z and Mininder S. Kocher, MD, MPH*z

appears to be a limitation to the procedure and necessitates

Background: Peroneal tendon subluxation is an uncommon aggressive physical therapy to maintain ankle motion.
cause of lateral ankle pain and instability but can be disabling Level of Evidence: Level IV— retrospective case series.
for some young patients. Surgical management may be required
to restore function for patients who fail nonoperative manage- Key Words: peroneal tendon subluxation, lateral ankle in-
ment. The purpose of this study was to determine the functional stability, calcaneofibular ligament transfer
outcomes after surgical management of peroneal tendon sub- (J Pediatr Orthop 2016;00:000–000)
luxation in pediatric and adolescent patients.
Methods: A retrospective review of patients presenting to our
institution over a 10-year period yielded 18 cases of recurrent
subluxation refractory to nonoperative management in 14 chil-
dren or young adults (mean age 15.0 y). All patients failed
P eroneal tendon subluxation is an infrequent but im-
portant source of lateral ankle pain and instability.1
Normally, the peroneus brevis and longus tendons are
nonoperative management and were treated operatively with
isolated calcaneofibular ligament transfer to construct a new soft
contained in the retrofibular groove by the superior per-
tissue restraint for the peroneal tendons. Patients were evaluated
oneal retinaculum (SPR).2 Disruption of the SPR is
clinically and sent validated questionnaires, including the Foot
commonly the result of traumatic injury to the ankle with
and Ankle Ability Measure (FAAM) and the American Or-
dorsiflexion and inversion of the foot and simultaneous
thopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot
muscular contraction of the peroneal tendons.2–5 It often
Scale.
occurs in sports that require cutting such as skiing, soccer,
Results: All 18 ankles of 14 patients had minimum 2-year follow-
basketball, ice skating, rugby, and gymnastics.1–3 Atrau-
up. Ten of 18 ankles (55.6%) returned the outcome surveys at an
matic peroneal tendon subluxation can occur in patients
average of 5.7 years after the index procedure (range, 2. 0 to
with a hypoplastic retrofibular groove or generalized lig-
9.7 y). The average FAAM activities of daily living score was
amentous laxity.1,2 Estimated to occur in 0.3% to 0.5% of
93.5 (± 2.9) and the sports subscale was 77.8 (± 6.1). The mean
traumatic events to the ankle, peroneal subluxation can
AOFAS subjective scaled score was 84.3 (± 4.5). All patients
result in posterolateral ankle pain, instability, and snap-
returned to sports and recreational activity. Complications in-
ping of subluxating tendons, which may limit daily and
cluded 1 case of recurrent subluxation (1/18, 5.5%) treated with
recreational activities.2,3,6,7
revision to a Chrisman-Snook procedure and 4 ankles (4/18,
Conservative treatment with casting for 6 weeks
22.2%) with stiffness or arthrofibrosis treated with a secondary
may be attempted in acute dislocation, but due to high
procedure of peroneal tendon release or lysis of adhesions.
rates of recurrence, surgical management is often required
Conclusions: Surgical management with rerouting of the per-
for chronic peroneal tendon subluxation in adults.2,7
oneal tendons under the calcaneofibular ligament appears to be
Since Jones’4 first description in 1932, 5 categories of
safe and effective for young patients with chronic peroneal
surgical repair techniques for peroneal subluxation in
tendon subluxation. It provides a low rate of recurrent sub-
adults have been described in the literature: anatomical
luxation, excellent stability, and good long-term functional
repair of the SPR,8 repair and reinforcement of the SPR
outcomes. However, the potential for postoperative stiffness
with tissue transfers,9 bone block procedures,5,10 groove-
deepening procedures,11,12 and rerouting of the peroneal
tendons under the calcaneofibular ligament (CFL).13–15
Despite the literature on peroneal tendon surgery in
From the *Harvard Medical School; wHarvard Combined Orthopaedic adults, there are limited studies on surgical management of
Residency Program; and zDepartment of Orthopaedic Surgery, Di-
vision of Sports Medicine, Boston Children’s Hospital, Boston, MA. peroneal tendon subluxation in pediatric and adolescent
None of the authors received any external financial support. patients because it is an uncommon entity in this pop-
The authors declare no conflicts of interest. ulation.16,17 In addition, the potential for damage to the
Reprints: Mininder S. Kocher, MD, MPH, Department of Orthopaedic distal fibular physis and resulting valgus deformity of the
Surgery, Division of Sports Medicine, Boston Children’s Hospital,
300 Longwood Avenue, Hunnewell 2, Boston, MA 02115. E-mail: ankle make osteotomy and groove-deepening procedures
mininder.kocher@childrens.harvard.edu. unsuitable for skeletally immature patients.17,18 The pur-
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved. pose of this report is to describe the functional outcomes

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Stenquist et al
and complications following surgical management of per-
oneal tendon subluxation in pediatric and adolescent pa-
tients using a previously reported CFL transfer technique.17
METHODS
A database search approved by the Institutional
Review Board was conducted to identify all patients
treated with CFL transfer for chronic peroneal tendon
subluxation recalcitrant to nonoperative management at
our institution between January 2003 and February 2013.
All patients were at least 2 years removed from surgery.
Both traumatic and atraumatic etiologies of peroneal
subluxation were included. Patients who underwent con-
current surgeries such as a Brostrom or modified Christ-
man-Snook procedure were excluded. Fourteen patients
(18 ankles) met all inclusion criteria. Six patients (8 an-
kles) were also included in the preliminary investigation
performed at our institution.17
A review of medical records and imaging was con-
ducted to determine age at diagnosis, mechanism of in-
jury, modes of conservative treatment attempted, peak
activity limitation, and physeal status. Tourniquet time,
length of hospital stay, and duration of follow-up were
also recorded. Chart review assessed the ability to return
to sports, time to sports return, and physical exam at the
most recent clinic visit. Persistent pain, recurrent or re-
sidual subluxation, and any reoperations were docu-
mented.
Patients were mailed the Foot and Ankle Ability
Measure (FAAM) questionnaire and the American Or-
thopaedic Foot and Ankle Society (AOFAS) Ankle-
Hindfoot Scale. Functional outcomes analysis was limited
to those 8 patients (10 ankles) who returned the ques-
tionnaires. The FAAM scale is valid for measuring
function in disorders of the leg, foot, and ankle.19 Al-
though the AOFAS scale has not been validated in its
entirety, the subjective component has been shown to
have acceptable validity regarding quality of life in foot
and ankle conditions.20 Activities of daily living (ADL)
score and sports score were calculated for the FAAM. A
subjective component score was calculated for the AO-
FAS Ankle-Hindfoot Scale. All scales are scored out of
100 possible points. Additional questions were included
on the survey to assess complications, satisfaction with
surgery, preoperative and postoperative pain, and sports
participation.
Operative Technique
All patients identified underwent an operative pro-
cedure by the 2 senior authors (M.S.K.: n = 13, D.E.K.:
n = 5), including CFL transfer and imbrication of the
SPR. Under tourniquet, a curvilinear incision of ap-
proximately 4.5 cm was made behind the lateral malleolus
over the peroneal tendons. The sural nerve was protected.
The peroneal sheath was opened near the level of the tip
of the fibula. The peroneal tendons were identified and
examined for tendon tear or rupture. The CFL was
identified as the floor of the peroneal sheath beneath the
peroneal tendons and sharply detached from the tip of the
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J Pediatr Orthop  Volume 00, Number 00, ’’ 2016
fibula. It was rerouted from a position deep to the per-
oneal tendons to a position superficial to the tendons. The
proximal end of the CFL was then secured to the peri-
osteum of the distal fibula with Ethibond sutures (n = 17)
(Ethicon, Blue Ash, OH) or a 2.4 mm Bio-SutureTak
anchor (n = 1) (Arthrex, Naples, FL). Care was taken to
keep this repair away from the physis to avoid damage to
the growth plate. The foot was taken through a range of
motion intraoperatively to assess for any residual sub-
luxation. The SPR was then imbricated over to the fibula
and repaired to its anterior aspect with 2-0 absorbable
suture. The peroneal tendon sheath was repaired followed
by closure of the subcutaneous tissues and skin.
Postoperative Management
Patients were kept non–weight-bearing for the first
2 weeks in a short-leg cast. At 2 weeks postoperatively,
the cast was removed and patients were transitioned to a
walking boot and made weight-bearing as tolerated.
Physical therapy was initiated at 2 weeks, with limitation
to dorsiflexion and plantar flexion (no inversion/eversion)
for weeks 2 through 6. The patients were placed into a
sports ankle brace at 6 weeks and inversion and eversion
motions were initiated. Patients were then allowed to re-
turn to sports at 12 weeks with a lace-up ankle brace and
home exercise program.
RESULTS
Our database review identified 18 ankles (14 pa-
tients, 10 female and 4 bilateral), mean age 15.0 years
(range, 6.8 to 22.6 y). Etiology of peroneal subluxation
was unidentified (1), atraumatic (5), or traumatic (12).
Traumatic injuries occurred during recreational activities
such as dancing (5) and football (2). Four ankles in the
series belonged to 2 patients with Ehlers-Danlos Syn-
drome or suspected connective tissue disorders.
All patients failed initial nonoperative management
with immobilization in a cast or a walking boot and
physical therapy before surgical management (except for
1 patient who developed painful subluxation of the
contralateral ankle while recovering from CFL transfer
on her first ankle). The mean time from diagnosis at our
institution to procedure was 7.5 months (although many
patients had initial management at an outside institution).
Preoperative symptoms included lateral ankle pain with
palpable subluxation or dislocation of the peroneal ten-
dons around the fibula documented on exam in all pa-
tients. Eight ankles (44.4%) specifically reported
limitation of ADLs before surgery and the remaining 10
ankles noted limitation of sports and other recreational
activities. Review of radiographs demonstrated no frac-
tures and an open distal fibular physis in 7 of 18 cases.
There were no intraoperative complications noted and 16
of 18 procedures were performed as day surgery. Patients
with bilateral subluxation underwent 2 separate operative
procedures (range, 3 to 23 mo between procedures).
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J Pediatr Orthop  Volume 00, Number 00, ’’ 2016
Postoperatively, 1 ankle developed recurrent per-
oneal tendon subluxation (5.5%, 1/18) that required re-
vision to a Chrisman-Snook procedure. Four ankles in 3
patients (22.2%, 4/18) had complications requiring sec-
ondary procedures including persistent lateral ankle pain
(1 patient, 2 ankles), new onset anterior-lateral ankle pain
(1 patient), and arthrofibrosis (1 patient). Secondary
procedures included peroneal tendon release or lysis of
adhesions. The average time from index procedure to
secondary surgery was 15 months (range, 5 mo to 2.6 y).
All secondary procedures were performed as day surgeries
and no recurrent instability or sequelae from complica-
tions were noted on last clinical follow-up.
All 18 ankles were at least 2 years out from surgery;
the last clinic visit was at a mean of 22.9 months post-
operatively (range, 3 mo to 7.3 y). No ankle had recurrent
subluxation or ankle instability. None of the patients re-
ported limitation in any ADLs and all those with sports-
related injuries had returned to sports with no recurrent
subluxation. Five of 18 ankles reported mild occasional
pain in the ankle during the last clinic visit. Three of these
5 ankles had required secondary procedures. The mean
time to return to full activity after index procedure was
3.4 months. Mean time to return to full activity after
secondary procedure was 3.6 months. Direct injuries to
the repaired ankle after full recovery were documented as
a result of normal recreational activities in 4 of 18 ankles.
Stability was maintained and there was no recurrent
subluxation on clinical exam in 4 of 4 ankles.
Ten ankles (55.6%) responded to outcomes surveys
including 4 who had required a secondary procedure
(Table 1). All patients rated their overall level of function
as “normal” or “nearly normal” except for 1 patient
with increased pain who rated her overall function as
“abnormal.”
There were no limitations of ADLs, but 6 of 10 an-
kles (60%) reported some limitation of recreational activ-
ities and difficulty ambulating on uneven terrain, whereas 4
(40%) reported a “popping sensation” in their ankle
posterolaterally. Three of these 4 ankles reported improved
pain as compared with before surgery. Nine of 10 reported
continued participation in sports or athletic activities and
all 10 indicated they would choose the same course of
treatment again. Finally, patients were asked to rate their
overall level of satisfaction with surgery and current
function on a scale from 0 to 10 (10 being very satisfied).
Mean satisfaction with surgery was 9.5 (± 0.3) and mean
satisfaction with current function was 8.7 (± 0.6).
DISCUSSION
Peroneal subluxation has been well described in the
adult literature, but data on incidence and treatment
options within the pediatric and adolescent population is
lacking. In pediatric and adolescent patients there is no
consensus on operative management and surgical options
are limited due to potential damage to the distal fibular
physis. We describe a modification of the CFL transfer
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Calcaneofibular Ligament Transfer
TABLE 1. Self-Administered Questionnaire Summary
(10 Ankles)
Questionnaire Mean ± SE (range)
Follow-up at questionnaire completion 5.7 ± 2.6 (2.0-9.7)
(y)
FAAM ADL score* 93.5 ± 2.9 (68.8-100)
FAAM sports score* 77.8 ± 6.1 (34.4-100)
Postoperative patient perception of 93.3 ± 2.6 (75-100)
ADL function (%)wz
Postoperative sports-related patient 89.9 ± 2.9 (75-99)
perception of function (%)w
AOFAS subjective scaled score 84.3 ± 4.5 (60-100)
Ankle pain: before CFL transfer/after 7.4 ± 0.3 (6-9)/1.9 ± 0.8 (0-8)
CFL transfery
*Scored out of 100 possible points.
wRated as a percent of function before ankle injury.
z9/10 ankles responded to this question.
yRated on a scale of 0-10, with 0 being no pain.
ADL indicates activities of daily living; AOFAS, the American Orthopaedic
Foot and Ankle Society; CFL, calcaneofibular ligament; FAAM, the Foot and
Ankle Ability Measure.
technique for treatment of chronic peroneal subluxation,
which is appropriate for skeletally immature and skel-
etally mature patients.
Transfer of the peroneal tendons behind the CFL
was first described by Platzgummer21 in 1967, and var-
iations of this technique using the CFL to create a tendon
restraint have since been reported in adults with good to
excellent results.13–15 Micheli et al22 described surgical
repair of peroneal subluxation in adolescent patients in
1989, using a sliding fibular graft procedure to treat
chronic peroneal subluxation in 12 adolescent athletes
with closed physes. Forman et al23 published the only
other documented surgical repair for peroneal sub-
luxation in a child with open physis in 2000, using a
variation of the Christman-Snook procedure.
We feel that suturing the CFL to the periosteum in
pediatric and adolescent patients is advisable to avoid
damage to the distal fibular physis (no physeal injuries
were noted in our series). Unlike some prior CFL transfer
methods, our technique preserves the peroneal tendons13
and obviates the need for groove deepening or hardware
insertion at or near the distal fibula.15,24 The procedure is
commonly done under short tourniquet time as a day
surgery.
There were 5 reoperations in our cohort. One pa-
tient required revision to a Chrisman-Snook procedure
due to recurrent subluxation after 2 eversion injuries
sustained within 3 months of surgery. This revision was
complicated by calcaneal osteomyelitis that resolved after
treatment with IV and PO antibiotics. The patient sub-
sequently developed sural neuritis and underwent sural
nerve exploration for excision of neuroma 4 years after
her index procedure. Upon last clinical follow-up 4.6
years after her index procedure, the patient reported no
ankle pain and had no residual subluxation. The sural
nerve is at risk with repeated lateral ankle operations, and
www.pedorthopaedics.com | 3
Stenquist et al
in 1 case series on surgical repair for peroneal tendon
dislocation in adults, scar pain and neuroma were the
most common complications.25 The remaining 4 compli-
cations in our cohort were due to postoperative stiffness
or impingement and each required peroneal tendon re-
lease or lysis of adhesions. Of note, 2 of 5 ankles requiring
secondary procedures had undergone 1 surgery before
CFL transfer due to anterior ankle impingement and
stiffness, potentially predisposing them to further scar
tissue formation and impingement.
Several studies have shown that loss of ankle mo-
tion and arthrofibrosis are associated with lateral liga-
ment reconstruction and soft tissue stabilizing procedures
about the ankle.11,26–28 Up to 10% to 30% of patients
may have chronic stiffness after conservative or surgical
treatment.26 In our study this is likely a result of the se-
cure restraint created by the CFL and postoperative im-
mobilization in the setting of soft tissue inflammation and
healing. However, while adhesions may occur, they do
not appear to affect long-term functional outcomes. After
release of the SPR and tenosynovectomy of the peroneal
tendons, no patient had recurrence of symptoms. Four of
5 ankles with reoperation returned surveys and all re-
ported having no difficulty with ADLs and only slight or
no difficulty with recreational activities. We utilize an
aggressive course of postoperative physical therapy to
maximize mobility, avoid stiffness, and minimize the
potential for arthrofibrosis. Intraoperative assessment
should ensure that CFL transposition and SPR repair
with imbrication is not restricting gliding of the tendons.
In this larger case series with longer follow-up, both
ADL functional score and sports subscale score were
higher compared with preliminary results published in
2010.17 However, the FAAM sports subscale score re-
mained lower than the ADL score and 6 of 10 ankles
(60%) reported some limitation of recreational activities.
However, 9 of 10 ankles reported returning to their
sport(s) and the tenth patient did not return to dancing
for reasons unrelated to her ankle function.
Four ankles (in 3 patients) reported a feeling of
popping in their posterolateral ankle. On the basis of
these patients’ functional outcomes, these symptoms
likely represent movement of the peroneal tendons within
the sheath created by the CFL. All 4 ankles had a normal
clinical exam on most recent follow-up and all patients
had returned to sports at their prior level. It appears these
symptoms are not disabling like the subluxation noted
before surgery, which prevented participation in sports.
However, further investigation of this possible intra-
sheath subluxation is needed to better characterize its
clinical significance.
Limitations of our study include the relatively small
number of patients and the retrospective, descriptive case
series design rather than randomization to treatment
groups. However, this peroneal tendon repair case series
is one of the largest to our knowledge, with the youngest
mean age at time of surgery. Comparative trials of dif-
ferent surgical techniques to determine optimal treatment
of peroneal tendon subluxation are needed but have not
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J Pediatr Orthop  Volume 00, Number 00, ’’ 2016
been conducted to date due to the relative rarity of these
injuries. Limitations of our functional outcome measures
include a lack of preoperative survey data for compar-
ison, and the potential for recall bias when asking patients
to retrospectively compare function and pain before and
after surgical intervention.
CONCLUSIONS
CFL transfer is a safe and effective treatment for
peroneal subluxation in pediatric and young adult
patients regardless of skeletal maturity. Results indicate
that this technique can largely prevent recurrent peroneal
subluxation, relieve pain associated with subluxation, and
ultimately improve quality of life by allowing return to
competitive sports activities with good to excellent long-
term functional outcomes for the majority of patients.
However, the reoperation rate is high and most cases of
reoperation were due to postoperative peroneal tendon
stiffness. The potential for postoperative stiffness appears
to be a limitation to the procedure and necessitates ag-
gressive physical therapy to maintain ankle motion.
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