The procedure is performed on an outpatient basis with the patient under
regional or general anesthesia. We prefer a combination of general anesthesia
utilizing a laryngeal mask with popliteal block augmentation for postoperative
pain control.
The patient is positioned in a lateral position on a well-padded beanbag
with the affected leg facing upward. After appropriate sterile preparation and
draping of the limb, the leg is exsanguinated and a calf tourniquet is applied
and inflated. A curvilinear incision is made over the path of the peroneal
tendons, immediately posterior to the fibula and extending just distal to its
tip, centered at the level of the peroneal groove. The incision is
approximately 8 cm in length and is safely located in the interneural plane
between the sural nerve posteriorly and the superficial peroneal nerve
anteriorly (Fig. 1). Dissection
is continued down to the superior peroneal retinaculum. The retinaculum is
examined for tears, distension due to stretching, or avulsion from the lateral
fibular insertion as seen in true peroneal subluxation
(Fig. 2), as classified by
Eckert and Davis4
and modified by
Oden5. The
retinaculum is then sharply dissected off the posterior aspect of the fibula,
leaving a 1-mm sleeve of retinaculum remaining attached to the fibular
periosteum for later reattachment (Fig.
3). The 1-mm rim of retinaculum and the adjacent periosteum are
sharply elevated off the fibula, leaving a flap that is later used to augment
the retinacular repair. The peroneal tendons are examined within the sheath,
and a tenosynovectomy is performed as needed. Tears in the peroneal tendons
(usually the peroneus brevis), as seen in type-B intrasheath subluxation
(Fig. 4-A), are addressed by
débridement and repair with a running 2-0 nonabsorbable suture to
tubularize the tendon (Fig.
4-B). If a very distal muscle belly of the peroneus brevis tendon
is found to extend into the peroneal groove region, it should be trimmed back
by sharp dissection so as not to increase the volume of the contents of the
groove.
Next, the retrofibular groove area is assessed. The tendons run over the
fibro-osseous floor of the groove. While it is normally a concave surface, it
is often flat or even convex (Fig.
5) in patients with subluxation of the tendons and this may be a
factor predisposing to the subluxation. The tendons are retracted and
protected, allowing access to the groove. An osteotome is used to osteotomize
the fibro-osseous sheath along with a thin sliver of bone from the posterior
aspect of the fibula (Fig. 6),
leaving a deep posterior periosteal sleeve intact to maintain stability and
vascularity of the bone fragment. The fibro-osseous flap is typically 3 to 4
cm in length and includes the entire posterior surface of the fibula. The
osteotomized groove is then hinged posteriorly in a trapdoor fashion, exposing
the underlying cancellous bone (Fig.
7). The flap, together with the peroneal tendons, is retracted and
protected with Hohmann retractors. A 3-mm round burr
(Fig. 8) is used to deepen the
peroneal groove by removing 7 to 9 mm of underlying cancellous bone from the
body of the fibula, creating a concavity
(Fig. 9) into which the tendons
can be replaced. The fibroosseous sheath, along with its osseous flap, are
then impacted back into the deepened groove with use of a bone tamp, leaving a
smooth and deepened floor over which the tendons can glide
(Fig. 10). A 0.062-in
(1.57-mm) Kirschner wire is then used to create a row of small drill-holes
(usually three or four) along the anterior lip of the roof of the deepened
groove (Fig. 11). The holes
are placed 3 to 4 mm from the edge of the fibula to prevent fracture during
suture placement and knot tying. A technical tip is to mark the drill-holes by
inserting the tip of a surgical marking pen after drilling, or they may be
difficult to locate when trying to pass the suture. The two peroneal tendons
are then reduced back into the deepened groove. Prior to retinacular repair,
the ankle is passively circumducted and the tendons should be observed to
glide smoothly without subluxating out of the groove or over each other. The
superior peroneal retinaculum is then reattached to the undersurface of the
deepened anterior lip of the peroneal groove
(Fig. 12) through these
drill-holes with use of 2-0 nonabsorbable braided suture. This allows optimal
healing of the cortical fibular flap into the raw osseous surface, covers the
rough leading fibular edge, and reattaches the peroneal retinaculum in a
reefed configuration so as to hold the peroneal tendons firmly contained
within the groove. Sutures are passed from the external osseous surface
through the drill-holes and the retinacular tissue. The suture is then moved
distally and reversed back through the retinaculum and the adjacent
drill-hole. No suture is tied until all have been passed (allowing direct
visualization of the tendon at all times and preventing accidental tendon
capture) along the line of drill-holes (Figs.
13-A and
13-B). The retinaculum is then
pulled into position under the anterior edge and is held in position while the
sutures are tied. The previously maintained sleeve of retinaculum and
periosteum is then advanced posteriorly and sutured in a pants-over-vest
manner to the posterior repaired peroneal retinaculum (Figs.
14-A and
14-B), augmenting the
retinacular reattachment by creating a double row repair. This is performed
with use of 2-0 nonabsorbable braided suture, again taking care to avoid
inadvertent capture of the underlying tendons. Testing peroneal sliding motion
is again undertaken by passive ankle circumduction.
Standard skin closure is undertaken with use of 4-0 absorbable subcutaneous
sutures and skin staples. A well-padded posterior U-splint is applied with the
foot and ankle in a neutral position for the first two weeks following
surgery.
Postoperatively, the patient is maintained non-weight-bearing for six
weeks, but flexion-extension motion of the ankle in the sagittal plane, to
allow gliding motion of the peroneal tendons, is started after two weeks. At
six weeks, the patient is allowed to bear weight as tolerated in a brace
designed to prevent eversion, dorsiflexion, and external rotation of the
ankle. Physical therapy for peroneal strengthening and proprioceptive training
is also started (out of the brace) six weeks after the operation. The brace is
discontinued after twelve weeks, and unrestricted activities, including
cutting maneuvers, are allowed as tolerated.
CRITICAL CONCEPTSINDICATIONS:Intrasheath subluxation of the peroneal tendons- Type A: There is no peroneal tendon tear, and the tendons momentarily
switch their relative positions (the peroneus longus tendon lies deep to the
peroneus brevis tendon).- Type B: The peroneus longus subluxates through a longitudinal tear in the
peroneus brevis tendon.Peroneal tendon subluxation out of the retrofibular groove (a retinacular
avulsion or tear)The same surgical technique is used for both intrasheath subluxation and
true peroneal tendon subluxation.RELATIVE CONTRAINDICATIONS:Recurrent dislocation or subluxation following a previous surgical
repair.- If there is inadequate retinacular tissue to reconstruct, a
calcaneofibular ligament or Achilles tendon transfer flap may be required to
hold the peroneal tendons reduced. If a groove-deepening procedure has not
been performed, this can still be done together with the transfer
reconstruction of the retinaculum.Prior open reduction and internal fixation of the fibula- The retinaculum may be deficient (see above).- Screws within the distal end of the fibula need to be removed to allow
the groove to be appropriately deepened.ABSOLUTE CONTRAINDICATIONS:An associated acute fibular fractureInfection within the planned area of surgeryPITFALLS:Failure to recognize the conditionInadequate repair of tears of the tendonsFailure to maintain the fibro-osseous sheath, resulting in friction and
adhesions of the peroneal tendons to the raw bone in the groove floorInadequate deepening of the groove, resulting in recurrent subluxationFailure to repair the retinaculum to the underside of the anterior aspect
of the fibula, resulting in failure of healing or attachment of the
retinaculum, or a retinacular reconstruction that may be inadequately tight to
hold the tendons within the grooveInadvertent capture of the peroneal tendons with a suture during
retinacular repair, resulting in inadequate motion or gliding of the peroneal
tendons during function and causing pain, stiffness, and weakness of the
peroneal tendonsFracture of the anterior fibular edge through a drill-hole, resulting in
failure of the suture to reattach the retinaculum and creating an inadequate
retinacular repairAUTHOR UPDATE:Since our original paper was published, no substantial changes have been
made in the surgical technique.
CRITICAL CONCEPTS
INDICATIONS:
Intrasheath subluxation of the peroneal tendons- Type A: There is no peroneal tendon tear, and the tendons momentarily
switch their relative positions (the peroneus longus tendon lies deep to the
peroneus brevis tendon).- Type B: The peroneus longus subluxates through a longitudinal tear in the
peroneus brevis tendon.Peroneal tendon subluxation out of the retrofibular groove (a retinacular
avulsion or tear)
Intrasheath subluxation of the peroneal tendons
- Type A: There is no peroneal tendon tear, and the tendons momentarily
switch their relative positions (the peroneus longus tendon lies deep to the
peroneus brevis tendon).- Type B: The peroneus longus subluxates through a longitudinal tear in the
peroneus brevis tendon.
- Type A: There is no peroneal tendon tear, and the tendons momentarily
switch their relative positions (the peroneus longus tendon lies deep to the
peroneus brevis tendon).
- Type B: The peroneus longus subluxates through a longitudinal tear in the
peroneus brevis tendon.
Peroneal tendon subluxation out of the retrofibular groove (a retinacular
avulsion or tear)
The same surgical technique is used for both intrasheath subluxation and
true peroneal tendon subluxation.
RELATIVE CONTRAINDICATIONS:
Recurrent dislocation or subluxation following a previous surgical
repair.- If there is inadequate retinacular tissue to reconstruct, a
calcaneofibular ligament or Achilles tendon transfer flap may be required to
hold the peroneal tendons reduced. If a groove-deepening procedure has not
been performed, this can still be done together with the transfer
reconstruction of the retinaculum.Prior open reduction and internal fixation of the fibula- The retinaculum may be deficient (see above).- Screws within the distal end of the fibula need to be removed to allow
the groove to be appropriately deepened.
Recurrent dislocation or subluxation following a previous surgical
repair.
- If there is inadequate retinacular tissue to reconstruct, a
calcaneofibular ligament or Achilles tendon transfer flap may be required to
hold the peroneal tendons reduced. If a groove-deepening procedure has not
been performed, this can still be done together with the transfer
reconstruction of the retinaculum.
- If there is inadequate retinacular tissue to reconstruct, a
calcaneofibular ligament or Achilles tendon transfer flap may be required to
hold the peroneal tendons reduced. If a groove-deepening procedure has not
been performed, this can still be done together with the transfer
reconstruction of the retinaculum.
Prior open reduction and internal fixation of the fibula
- The retinaculum may be deficient (see above).- Screws within the distal end of the fibula need to be removed to allow
the groove to be appropriately deepened.
- The retinaculum may be deficient (see above).
- Screws within the distal end of the fibula need to be removed to allow
the groove to be appropriately deepened.
ABSOLUTE CONTRAINDICATIONS:
An associated acute fibular fractureInfection within the planned area of surgery
An associated acute fibular fracture
Infection within the planned area of surgery
PITFALLS:
Failure to recognize the conditionInadequate repair of tears of the tendonsFailure to maintain the fibro-osseous sheath, resulting in friction and
adhesions of the peroneal tendons to the raw bone in the groove floorInadequate deepening of the groove, resulting in recurrent subluxationFailure to repair the retinaculum to the underside of the anterior aspect
of the fibula, resulting in failure of healing or attachment of the
retinaculum, or a retinacular reconstruction that may be inadequately tight to
hold the tendons within the grooveInadvertent capture of the peroneal tendons with a suture during
retinacular repair, resulting in inadequate motion or gliding of the peroneal
tendons during function and causing pain, stiffness, and weakness of the
peroneal tendonsFracture of the anterior fibular edge through a drill-hole, resulting in
failure of the suture to reattach the retinaculum and creating an inadequate
retinacular repair
Failure to recognize the condition
Inadequate repair of tears of the tendons
Failure to maintain the fibro-osseous sheath, resulting in friction and
adhesions of the peroneal tendons to the raw bone in the groove floor
Inadequate deepening of the groove, resulting in recurrent subluxation
Failure to repair the retinaculum to the underside of the anterior aspect
of the fibula, resulting in failure of healing or attachment of the
retinaculum, or a retinacular reconstruction that may be inadequately tight to
hold the tendons within the groove
Inadvertent capture of the peroneal tendons with a suture during
retinacular repair, resulting in inadequate motion or gliding of the peroneal
tendons during function and causing pain, stiffness, and weakness of the
peroneal tendons
Fracture of the anterior fibular edge through a drill-hole, resulting in
failure of the suture to reattach the retinaculum and creating an inadequate
retinacular repair
AUTHOR UPDATE:
Since our original paper was published, no substantial changes have been
made in the surgical technique.