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.
