One can correct chronic peroneal subluxation or peroneal instability through a variety of techniques described in the literature, typically involving tendon rerouting, fibula osteotomies or groove deepening.33-52
The aim of a tendon rerouting or tissue transfer technique is to reinforce the incompetent superior peroneal retinaculum and aid in retaining the peroneal tendons. These are often revision procedures with significant scar tissue and aberrant anatomy and the literature has described non-anatomic repairs with Achilles tendon slips, a calcaneofibular flap, a calcaneofibular ligament with a bone block, sub-calcaneofibular flap transposition, a peroneus brevis tendon slip and peroneus quartus.33-39
Bone block or fibula osteotomies may also prevent further subluxation and dislocation. In 1920, Kelly described an osseous procedure whereby one creates an osteotomy in the sagittal plane, splitting the distal fibula, and rotating the osteotomy clockwise and translating it posteriorly 6 mm.40 This creates a posterolateral fibular lip, which one would fixate with screws. Researchers have elucidated modifications to this procedure with good results.41,42 These are salvage procedures and require osseous union to occur, which will delay postoperative physiotherapy.
Groove deepening has become a well-integrated technique to indirectly reduce the propensity of the peroneal tendons to sublux in a more shallow retromalleolar groove. Researchers have also shown that these procedures decrease the overall pressure within the middle and distal retromalleolar groove.43 As Edwards found in his anatomic studies, the depth of the retromalleolar groove was approximately 3 mm and width was approximately 6 mm.5
In 1979, Zoellner and Clancy described the first groove deepening procedure, in which surgeons raised a cortical osteoperiosteal flap along the posterolateral distal fibula.44 With the tendon sheath opened and peroneals retracted anteriorly, surgeons curetted the cancellous bone to create a groove that was 6 to 9 mm deep. They tamped this osteoperiosteal flap back in position in a press-fit manner. This was the first direct deepening surgeons performed to reduce peroneal subluxation and all nine patients returned to their preoperative “athletic endeavors.” McGarvey and Clanton reproduced this procedure and reported a 30 percent complication rate.45 Porter and coworkers also reported on an osteoperiosteal flap and superior peroneal retinaculum augmentation in 14 patients with accelerated rehabilitation with no complications or recurrences.46
In 2009, Raikin reported on 14 patients with intrasheath subluxation diagnosed with dynamic ultrasound.47 He performed a posterior open trapdoor flap of the fibula at the level of the retromalleolar groove and used a rotary burr to deepen the groove. He repaired the flap with non-absorbable sutures through drill holes in the anterior fibula. American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were improved over 33 months from 61 points to 93 points and nine of 14 patients reported excellent results.
Shawen and Anderson have also described and popularized indirect deepening procedures.25 The authors introduced the idea of a solid core drill bit and sequentially reaming the posterior cancellous fibula until one can use a tamp to deepen the groove 3 to 8 mm. This procedure is advantageous because it avoids an open osteotomy and surgeons can perform it with a low learning curve. It is imperative to confirm the drill is within the fibula and not in the lateral gutter, which one can avoid by first using a cannulated drill and guide wire.