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.
