A 54-year-old former baseball pitcher with recurrent lateral ankle snapping and sensation of giving way with pain needs help. Know what to do? Three top docs tackled this question at the 2018 Orthopaedic Summit Evolving Technologies, held in Las Vegas this past December.
Robert B. Anderson, M.D. made (what he thought was) a good case for repairing the tendon sheath WITHOUT any bone osteotomy.
Sam Labib, M.D wasn’t convinced, “This is a Chronic Problem: You Have to Be Aggressive to Prevent Recurrence: Open Fibular Groove Deepening Please!”
Then Troy S. Watson, M.D., threw water on both of his colleagues—“You Are All Wrong: Debride & Stabilize With a Fibular Osteotomy—I Don’t Want a Recurrence!”
Whew!
This is a great discussion. Here are the details from three of the top sports medicine physicians in the United States.
Robert B. Anderson, M.D.: “Repair the Tendon Sheath Without Any Bone Osteotomy”
As we talk about peroneal tendon subluxation, remember that the superior peroneal retinaculum (SPR) and calcaneofibular ligament lie in the same vectors. If you have an inversion injury, you can rupture both. That’s why so many peroneal tendon issues come along with lateral ankle instability, lateral ankle sprains and such.
Subluxation can occur from a different number of different ways. One is inversion. You can rupture your calcaneofibular ligament and your SPR causing the tendon to sublux. The second is a forced dorsiflexion against active plantar flexion. Also, a calcaneal fracture.
Once you have an attenuated, ruptured, avulsed superior peroneal retinaculum, non-operative management is very difficult and highly unsuccessful.
There are many different classes or grades of peroneal tendon subluxation, 1 through 4. The most important to know about is a grade 3 which is a true avulsion of bone. The reason that it’s important is because it may be one that can’t be fixed operatively with simple ORIF [open reduction and internal fixation] techniques.
A lot of peroneal tendon subluxations occur with split tears in the peroneal tendon. If it’s a peripheral tear, you can excise and taper. If it’s central, you can debride and repair with an absorbable type suture.
When you’re talking about operating on a peroneal tendon subluxation, you have to first decide is this an acute or chronic event? Then, what is the associated pathology? Are there tendon issues? Are there bone issues? Are there joint issues that you may also have to consider?
When you’re looking at the acute superior peroneal tendon avulsion with the so-called “Fleck sign,” the type 3 ones are very amenable to ORIF if the fragment is of adequate size.
What about the other types that don’t have an avulsion? The true superior peroneal retinacular ruptures are attenuations. These are difficult to repair in isolation.
One that’s chronic, that’s been there for over 6 months, will always require fibular groove deepening with the SPR reconstruction. If you get a recurrent subluxation, you can even consider transposing in the calcaneofibular ligament over the top of the peroneals.
Where did I come up with this? This is something that we presented to AOFAS [American Orthopaedic Foot & Ankle Society in 1997. Hodges Davis and I had 17 patients, 10 chronic, 7 acute that we managed surgically. Nine had fibular groove deepening with an SPR repair, 8 had SPR repairs alone. There was a significant recurrence in those with chronic subluxation and who had an isolated SPR repair. The conclusion was chronic cases require a fibular groove deepening with SPR reconstruction repair.
