How To Manage Peroneal Tendon Subluxation

Start Page: 62

Additional Tips, Pearls And Insights

• Most often, subluxing peroneal repairs are in conjunction with a lateral ankle stabilization (Broström) procedure so a slightly more anterior and longer incision is necessary.

• Researchers recently described a slightly posterior incision for a combined Dwyer calcaneal osteotomy and superior peroneal retinaculum repair.52

• Use a flat tamp as depicted on page 3 to cover a broader surface.

• Absorbable sutures are recommended for repair to avoid suture knot irritation.

• Early postoperative mobilization is a key to avoid tendon scarring and adhesion.

Jeffrey E. McAlister, DPM, and Terrence M. Philbin, DO

What You Should Know About Post-Op Protocols

Postoperative protocols for peroneal subluxation and peroneal repairs are similar for us unless the operation is limited to a peroneal tenosynovectomy without repair. Initially, place the patient in a bulky Jones dressing with a plaster posterior splint in slight inversion with the ankle at 90 degrees. The patient is non-weightbearing for 10 to 14 days. At this point, one removes the sutures and the patient wears a non-weightbearing fiberglass short leg cast for four to six weeks. Following this period of immobilization, the patient will begin weightbearing in a high-top fracture boot, barring any corrective osteotomy.

   The patient will then begin formal goal-oriented physiotherapy focused on passive range of motion and proprioception at eight weeks. There needs to be a strong and linked relationship with physiotherapy for optimum outcomes and satisfaction.
We recommend three two-week phases of physiotherapy. The first phase focuses on progressive weightbearing in a regular shoe and joint mobilization in an athletic ankle brace. The second phase focuses on proprioception and increasing range of motion. Subsequently, the focus shifts to strength and returning to preoperative activity. At the three-month mark, evaluate the patient for a formal return to activity assessment.

   Pending satisfactory goal achievement, the patient then transitions into foot orthoses. If one did not perform a peroneal repair or subluxating peroneal repair, use a more aggressive postoperative weightbearing status. The patient transitions at the first postoperative visit into a tall fracture boot with physiotherapy beginning at three to four weeks postoperatively.

In Summary

Management of subluxing or dislocating peroneals in an acute or chronic situation, especially in an athlete, involves prompt diagnosis and intervention. The literature is abundant with level IV case series that support operative correction with a direct repair of the superior peroneal retinaculum and a groove deepening. More comparative, prospective studies need to occur for a higher level of recommendation.

   Dr. McAlister is a Fellow of the Orthopedic Foot and Ankle Center in Westerville, Ohio.

   Dr. Philbin is a fellowship-trained foot and ankle surgeon who is currently in private practice in Westerville, Ohio.

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Dr. Manoj Lal, DPMsays: September 18, 2013 at 3:35 pm

Great article! Keep up the good work, fellow alum.

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