3-Ways to Fix a 54-Year-Old Former Pitcher

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.

The same time that we came out with this paper, I was toying with this new procedure called the indirect fibular groove deepening or deepening without an osteotomy. It was what I called an “eggshell procedure,” where I ground out the inside of the distal fibula and I just basically impacted the very thin shell of bone into itself to create a deeper groove and then repair the SPR.

If you open up the skin, you will see an attenuated superior peroneal retinaculum. When you have that situation and you have a very shallow groove, you need to do something to deepen that groove.

The first thing we do is debride any redundant tissue around the peroneal tendons. I like to take away any redundant peroneus brevis muscle that may be low lying, trying to get myself more room in the area of the fibular groove to see what we’re doing.

It is a very minimally invasive technique. I come in right around with an insertion of the calcaneofibular ligament and we successfully size drill bits to hollow out the distal fibula. So, we are creating like an eggshell. If you have very hard bone, you can weaken it and then you take a big impactor and you impact that shallow bone; then you take that weak bone and you basically and impact it into itself.

You’re creating a deepening effect, accentuating the sulcus. From there you can prepare your SPR. When you’re done with the groove deepening without an osteotomy, those tendons are now inherently stable back underneath the accentuated posterolateral rim of a distal fibula. From here we drill holes in the back of the fibula itself and will advance the superior peroneal retinaculum back to that edge and tighten it all up.

Get these people in a splint for 2 weeks, weight bearing boot walking for 4 weeks. Most of my athletes are back on the field, even back to playing by 8 to 10 weeks after this particular procedure.

At last summer’s meeting of the AOFAS, we compared all different techniques and found the indirect technique had no revisions and no recurrent dislocation. Indirect had better outcomes than the direct osteotomy type of group deepening procedures which had a higher percent of dislocated tendons than indirect.

The summary: you first need to differentiate between chronic and acute. If they have an avulsion and they’re acute they may be amenable to ORIF. The only way you can get away with a simple soft tissue repair in an acute injury is if they have a very concave sulcus. If they have a very shallow groove and they’re acute, I would highly recommend a procedure like this indirect groove deepening that’s minimally invasive, does not require an osteotomy, and it has been shown to work.

Sam A. Labib, M.D.: “This is a Chronic Problem: You Have to Be Aggressive to Prevent Recurrence: Open Fibular Groove Deepening Please”

I’m happy that Bob agrees that groove deepening is a good idea because I want to say more about the same. There’s a cadaveric study from 1927 that took 100 cadavers and found that 82% of us have a concave sulcus, 7% have a convex sulcus, and 11% had a flat sulcus. They did not study if these 11% or 7% had more instability. Like Dr. Anderson said, there’s an acute way to get this and a chronic way. My job is to describe why we should do groove deepening in the chronic situation.

There’s a classification by Eckhart and Davis. There’s Grade One, which is soft tissue, Grade Two, where there’s a small fibrous rim that peels off, and Grade Three is a small piece of bone which is the Fleck sign. This can be treated accordingly. We need to know the grades and we need to know what we’re looking for and we need to look for peroneal tendon injury.

What happens to the tendon tears? If damage in the tendon was less than 30%, we excise it and then tubularize the tendon. If it’s 30 to 75%, we repair it. I don’t repair a split, but I do trim it and then tubularize it. If you have a more than 75% or large area of the tendon missing, then you can do a tenodesis of the longus to the brevis or the brevis to the longus.

The International Consensus Statement on Peroneal Tendon Pathology suggests if you have a dislocation and it’s acute, you do surgical management. If you have dislocation and it is an athlete, you consider groove deepening. If you have a chronic dislocation you definitely do a groove deepening as well. They found that acute injuries and athletes can utilize groove deepening for added stability and definitely in chronic injuries especially in convex anatomy.

Dr. Anderson showed us a U-shaped technique. You create the U, you scrape behind it, and then you tap it in. That’s one way to do it. This is not the way I do it. I personally go and create a cut behind the fibula, open up an osteoperiosteal flap, and then curette behind it. And use a burr sometimes and then tap it in place, reduce it, and repair it. This has worked very well for me and my patients.

In conclusion, operative treatment is always indicated in the chronic dislocated tendon. Look for the tendons and repair them. Groove deepening is a good option if done well and long-term results are excellent in return to sports.

Troy S. Watson, M.D.: “You Are All Wrong: Debride & Stabilize With a Fibular Osteotomy – I Don’t Want a Recurrence”

I’m going to do my best to convince you guys that maybe the fibular osteotomy is a reasonable option. The acute peroneal tendon dislocation is often missed initially, but it’s really not a super common diagnosis. I maybe see two or three of these a year and I take care of most of UNLV Athletics, so it’s just not super common. We already looked at anatomy. We looked at the various different grades.

Basically, the diagnosis is made with history and physical exam. Usually these athletes will report pain and a snap over the posterior fibula, pain and swelling over the SPR, and pain with eversion.

Should we fix the acute tears or is there any indication for non-operative treatment? Many authors favor surgical management for the acute injury. This is because there’s a high incidence of recurrence in the non-operative patient population, predominantly young athletes wanting to get back to play so treating them non-operatively if they have the same problem, you’re just delaying the time to return to sport.

There is a belief that subacute subluxation may lead to longitudinal split tears of the peroneal brevus tendon. That could be basically used to support our desire to take these patients to surgery earlier with uniformly excellent results with surgery in the acute injured patient.

All procedures for chronic injuries fall into one of five categories. We’ve already heard about direct repair of the SPR and groove deepening procedures. There’s also others that were not going to talk today: tissue transfer procedures or re-rooting procedures. We’re going to mainly talk about the bone block procedures in the time we have left.

Fibular osteotomy or rotational osteotomy was originally described in the British JBJS back in 1920 by Dr. Kelly. He called this a veneer graft, like a little thin layer of wood. It’s a thin piece of the fibula that you’re cutting and rotating to gain coverage. DuVries modified this. In a 1984 study, he used a smaller graft that he brought posteriorly and fixed with a screw. But there was a lot of perioperative complications with malposition of the screw, fractures of the graft, so that procedure has been largely aborted.

A modified version of Kelly’s procedure was published in A Journal of Sports Medicine in 1996. Rotation of graft and repair the SPR to contain the tendon; 9 of 11 ankles achieved excellent clinical results. They did warn us about the concomitant ATFL [anterior talofibular ligament] tears.

There is another procedure where they take the central portion of the fibula and bring it down and then fix it with a couple of screws. There is only one published paper but they also had excellent results.

In summary, for chronic peroneal tendon subluxations, we believe these do best with surgical intervention. No study has shown superiority over other procedure, so there’s been no study published data that compares techniques. Rotational fibular graft associated with excellent results and few complications. It’s simple, it works, and avoids disturbing the retrofibular region.

Please visit orthosummit.com for more information on this year’s upcoming event on December 11-14, 2019 at the Bellagio in Las Vegas, Nevada.