Pertinent Pointers On Surgical Decision Making
The decision for surgical intervention for peroneal tendon pathology can be complicated when dealing with athletes. One needs to assess the possible degree of disability and the likelihood of further injury when forming a treatment plan. If left untreated, subluxation of the peroneals can lead to tendon tears or ruptures, and further long-term damage. Any injury that causes an athlete to deviate from the normal biomechanics may predispose the athlete to a secondary injury. A prospective study in the American Journal of Epidemiology found high school athletes with a previous injury to be twice as likely to be reinjured in comparison to athletes with no prior injury.11 In regard to the decision to undergo surgical intervention, the surgeon discusses this idea earlier on in the treatment plan when it comes to athletes with peroneal subluxation or other contributing pathology.
The timing of surgical intervention can be very important in our athletic patients. Consider aggressive non-surgical treatment, such as functional bracing and daily rehabilitation, when patients are in season and demonstrate normal biomechanics with minimal pain. The beginning of the off-season is the ideal time for surgical intervention as this allows for a proper healing and rehabilitation. With year-round athletes, the timing of surgery may be of less importance. One should consider surgery after conservative treatment has failed and it should be based on the severity of symptoms and type of pathology.
A Step-By-Step Approach To Surgical Intervention
Surgical intervention for peroneal tendon injuries should address both tendon pathology and associated deformities. Isolated tendon debridement or repair, in the presence of concomitant deformities, may lead to less than desirable results. Other associated conditions that one may need to address include lateral ankle instability, osteochondral lesions or varus deformities.
Typical exposure of the peroneal tendon complex includes a curvilinear incision beginning proximal to the ankle joint over the posterior fibula and extending distally along the course of the peroneal tendons to the level of the peroneal tubercle. After carrying dissection down to the superior peroneal retinaculum and tendon sheath, perform active circumduction to evaluate for the presence of subluxation.
Although it is less common, intrasheath subluxation can occur. This involves the tendons switching their alignment while maintaining position in the fibular groove.12 When gross subluxation or intrasheath subluxation is present, the surgeon should evaluate the local anatomic etiology. This evaluation includes identification of a shallow fibular groove, a low-lying peroneus brevis muscle belly and the presence of peroneus quartus. Excise these soft tissue anatomic anomalies to decompress the fibular groove and reduce the potential for subluxation.
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.