After incising the common tendon sheath, displace the tendons from the fibular groove and inspect them. When present, excise inflamed synovial tissue. Evaluate tears in the peroneal tendons according to their cross-sectional involvement. In regard to tears with less than 50 percent involvement, perform direct debridement with or without tubularization. When it comes to tendons with a flattened appearance and greater percentage of tendon involvement, perform tubularization with non-absorbable sutures. To reduce soft tissue irritation, bury the suture knots within the tubularized portion of the tendon.
Tears with more than 50 percent involvement typically receive proximal and distal tenodesis using non-absorbable sutures. Those percentages are important guidelines as the ultimate decision is based on the intraoperative assessment of the tendon and the quality of the remaining tendon. Consider tendon graft or local tendon transfer in the presence of a decreased tendon excursion.
Create a shallow fibular groove to reduce the potential for chronic subluxation. Researchers have described numerous techniques to deepen the retromalleolar groove and prevent resubluxation.13-15 Other procedures include simple bony resection, fibula bone block advancements or periosteal flaps.
The approach we typically utilize with athletic patients is an intramedullary groove deepening procedure as described by Mendicino and colleagues.16 One would perform graduated intramedullary reaming of the posterior aspect of the fibula, taking care not to invade the gliding surface of the fibula. The surgeon can easily perform this under fluoroscopic image intensification. Gently impact the posterior surface with a bone tamp. Doing so allows for an increase in groove depth while maintaining a smooth surface for the tendons to glide over in the fibular groove.
In addition to repair of direct tendon and fibular groove pathology, evaluate the competency of the superior peroneal retinaculum. Insufficiencies associated with the retinaculum can range from fracture or separation of the fibrocartilagenous lip to simple attenuation. Restoration of the integrity of the retinaculum is the goal for these types of injuries.
Our most commonly employed technique in this scenario involves resection of redundant retinaculum with advancement of the retinaculum. The surgeon advances the posterior aspect of the superior peroneal retinaculum anteriorly and secures it to the posterior lateral ridge of the fibular using non-absorbable sutures passed through drill holes. Advance the anterior aspect of the retinaculum posteriorly and suture it in a pants-over-vest fashion to the posterior portion of the retinaculum. At the completion of the procedure, perform circumduction of the ankle to ensure adequate stability of the tendons in the retromalleolar groove.
Ensuring A Smooth Postoperative Course
Postoperative protocols depend on the procedures one performs. In the absence of osteotomies or arthrodesis procedures, our postoperative course for peroneal repairs includes a 10- to 14-day period of non-weightbearing in a combined compression dressing and posterior splint until we remove the sutures. During the next two weeks, the patient wears a removable walking boot and physical therapy begins with a focus on early mobilization and edema control.
At four to six weeks, the patient may start protected weightbearing. Physical therapy sessions focus on improving range of motion and strengthening of the peroneal complex. One should utilize deconditioning prevention in physical therapy and can include strengthening exercises of the hip and thigh muscle groups.