Ogawa and colleagues performed a similar procedure on 15 patients and reported statistically significant poorer outcomes in patients requiring additional peroneal tendon repair versus isolated peroneal subluxation.48 Similarly, Saxena and Ewen reported on a cohort of 31 athletic patients who showed a tendency for a longer return to activity with additional peroneus brevis tear repairs.49 Again, multiple anatomic studies have shown a concave retromalleolar groove to be common and we have a low threshold for groove deepening.2,5
The literature is abundant with level III and IV studies on this topic. Given the complexity and paucity of peroneal subluxation cases, there has only been a grade I recommendation for the procedures described.50
A Closer Look At The Authors’ Surgical Technique
Our preferred technique for direct superior peroneal retinaculum repair with groove deepening involves a sharp excision of a 1 to 2 mm cuff of retinaculum at the posterolateral border of the fibula.51 Debride the peroneal tendons and repair them as necessary with absorbable sutures. Resect any atypical bulky, low-lying peroneus brevis muscle belly by electrocautery to prevent bleeding.
At this time, assess the retromalleolar groove for shape and bring the tendons through passive range of motion to evaluate for subluxation with circumduction and eversion of the ankle. With the tendons retracted, make a sharp periosteal incision at the tip of the fibula, lateral to the calcaneofibular ligament. Then insert a 3.5 mm solid drill in parallel to the retromalleolar groove and ream the distal fibula proximally about 2 to 3 cm. Then use a small curette to further debride and soften the fibrocartilage of the groove. Proceed to utilize a small, flat tamp to deepen the groove until attaining a desired depth (approximately 6 to 8 mm) to prevent dislocation.
Once the retinaculum is amenable to direct repair, resect the posterolateral border of fibula with a rongeur to allow for a fresh, bleeding bed. Then sharply elevate a lateral periosteal flap to assist in suture repair and perform a pants-over-vest suture repair technique, reinforcing the superior peroneal retinaculum with absorbable sutures. Take care to avoid inadvertently suturing the tendons when repairing the superior peroneal retinaculum.
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.