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Novel Technique Developed for Surgical Treatment of Peroneal Tendon Dislocation

Key findings

  • More than 20 techniques have been described for surgical treatment of peroneal tendon dislocation
  • Some of these techniques may unduly disturb the important anatomic facets meant for retention in the retromalleolar groove
  • A modified retromalleolar groove-deepening technique developed at Massachusetts General Hospital is designed to preserve the natural gliding layer of fibrocartilage and prevent iatrogenic damage
  • This technique is believed to be useful for addressing all anatomic variations of the posterior distal fibula and retromalleolar groove

The optimal surgical approach to peroneal tendon dislocation is still being debated, with more than 20 techniques described. Most of these involve both repair of the superior peroneal retinaculum (SPR) and deepening of the retromalleolar groove. A systematic review suggests that athletes return to sports sooner after the combination technique than after SPR repair alone.

However, there is variation among surgeons as to whether and how to preserve the natural fibrocartilaginous surface along the posterior lateral malleolar surface of the retromalleolar groove. Cortical abrasion of that surface or forceful cortical impaction has unknown consequences for peroneal gliding.

Foot & Ankle Center Chief Christopher W. DiGiovanni, MD, and Orthopedic Surgeon Daniel Guss, MD, of Massachusetts General Hospital, developed a modified retromalleolar groove–deepening technique that is designed to:

  • Preserve the gliding layer of fibrocartilage
  • Prevent iatrogenic damage by reducing the force needed for creating the bony flap and then impacting the posterior fibula
  • Enable a single-step centralized reaming technique to avoid the possibility of eccentric or unpredictable cortical flap creation

The details of the technique were published in The Orthopaedic Journal of Sports Medicine. In brief, they deepen the groove using sequential, cannulated reaming of the intramedullary canal, rather than relying on multiple small drill holes. They use a thin and narrowly curved saw instead of an osteotome because the saw requires less force on the distal fibular bone.

Taken together, they say, these measures allow the posterior cortex to be tamped down with almost no force, preserving the integrity of the fibrocartilage gliding layer. The sequence is easily expandable if additional depth is necessary, without fear of compromising the initial construct.

Over the past five years, the study’s two senior authors, Dr. DiGiovanni and his colleague, Alastair Younger, MB, ChB, of the Department of Orthopaedics at the University of British Columbia, have collectively performed more than 60 procedures using this technique and have seen no complications. They do caution that several precautions must be taken:

  • Identify and protect the sural nerve, particularly during reaming of the fibula
  • Remain alert to the sural nerve’s location during retinacular closure, to avoid iatrogenic entrapment
  • Avoid overtightening of the retinaculum, which can result in retinacular tearing or overconstraint and lead to symptomatic stenosis

Drs. DiGiovanni and Younger believe that this technique is useful for all anatomic variations of the posterior distal fibula and retromalleolar groove. They recommend it for repair of chronic dislocated peroneal tendons, recurrent dislocating peroneal tendons and dislocation of the tendons after acute injury in patients with a shallow fibular peroneal groove.

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