Dislocation or Subluxation

Acute Operative management is considered in the young athletic population. There is a high failure rate of conservative treatment and a better success rate with surgery. Superior peroneal retinacular repair will address acute subluxation or dislocation. The patient can be placed in a prone, lateral, or supine position; we use the lateral position. A 7-cm longitudinal incision, 1 cm posterior to the fibula and following the tendons, is used. The sural nerve is identified and protected. The superior peroneal retinaculum is identified and the defect located. Each tendon should be inspected for concomitant defects. The tendons are retracted and the fibular groove is inspected. If the groove is shallow, flat, or convex, the groove is deepened. The superior peroneal retinaculum is repaired by placing three to four drill holes in the posterolateral margin of the fibula. The sutures

Tendon Tubularization

Figure 69-1 Intraoperative photographs of longitudinal peroneus brevis tear requiring tubularization. A, Planned incision along the course of the peroneal tendons; B, identified tear in the peroneus brevis; C, tubularized tendon; D, debrided portion.

Figure 69-1 Intraoperative photographs of longitudinal peroneus brevis tear requiring tubularization. A, Planned incision along the course of the peroneal tendons; B, identified tear in the peroneus brevis; C, tubularized tendon; D, debrided portion.

through the superior peroneal retinaculum are advanced through the drill holes. Finally, the retinaculum is imbricated for reinforcement.

Chronic There is a multitude of surgical procedures described to address chronic peroneal dislocation: retinaculum reinforcement and repair, tissue transfer, tendon rerouting, bone block, and groove deepening are discussed here.

Superior peroneal retinaculum reinforcement entails the same technique as with acute repair. If a fibula avulsion fracture exists, then open reduction and internal fixation are recommended. The advantages of this repair include a small incision, anatomic approach, and avoidance of an osteotomy. The potential disadvantage of this procedure is the failure to correct predisposing anatomy, such as sulcus deformities and insufficient retinaculum.

Tissue transfers use tendons and periosteal flaps from other places to recreate or reinforce the superior retinaculum. The most common procedure was described by Jones using a distally attached slip of the Achilles tendon routed through the fibula.

This stabilizes the peroneals and reinforces the retinaculum. Modifications using the plantaris or peroneus brevis have also been reported.

Tendon rerouting relies on the calcaneofibular ligament to constrain the peroneal tendons. Four methods of tendon rerouting have been reported.

Platzgummer described dividing the calcaneofibular ligament near the fibular insertion and suturing it over the tendons.10 A modification of this was described by Sarmiento and Wolf who transected the peroneal tendons, passed them below the calca-neofibular ligament, and then repaired them.10

Pozo and Jackson demonstrated another technique, taking the calcaneofibular ligament origin with a predrilled piece of distal fibula.10 The tendons were replaced in the sulcus and the fibula reattached with screw fixation. Poll and Duijfjes reversed this procedure by detaching the insertion of the calcaneofibular ligament with a predrilled piece of the calcaneus.10

Bone Block Bone block procedures attempt to contain the peroneal tendons using the fibula. This procedure was first described by Kelly in 1920 by using a partial thickness osteotomy of the distal fibula rotated posteriorly to deepen the fibular groove. DuVries modified this technique by driving a wedge of fibula posteriorly to hold the dislocating peroneal tendons.10

Groove Deepening Groove deepening addresses the shallow or absent retromalleolar groove that often exists in cases of peroneal subluxation or dislocation. The classic groove deepening and newer methods are described. The patient is positioned in the lateral decubitus position. A curvilinear incision starting 5 to 6 cm proximal to the tip of the fibula is made, ending just distal to the fibula. The sural nerve is identified and protected throughout the entire procedure. The entire sheath and reti-naculum are visualized prior to incising them just posterior to the border of the fibula. The peroneal tendons are inspected for any associated pathology. Some form of tendon pathology usually exists, primarily longitudinal tearing, and this must be addressed intraoperatively. The retromalleolar sulcus is exposed. Often the groove is shallow, ranging from flat to convex. A saw is used to create a 3-cm long X 1-cm trapdoor within the fibula that is hinged medially (Fig. 69-2). An osteotome is used to elevate the trapdoor. A curet is used to remove 7 to 9 mm of cancellous bone before reinserting the flap into the deepened bed. The retinaculum and periosteum are reattached to the pos-terolateral border using suture placed through drill holes. The superior peroneal retinaculum is reinforced simultaneously.

The more recently described groove-deepening technique is generally easier to perform. Once the retromalleolar sulcus is exposed, an incision just anterior to the origin of the calcane-ofibular ligament is made. Care is taken not to incise the calca-neofibular ligament. A periosteal elevator is used to mobilize the soft tissue at the distal fibula. The medullary canal is then reamed using sequential drill bits. The drilling is started at the distal tip of the fibula and advanced proximally into the shaft. The drill bit size is sequentially increased at the most posterior portion of the fibula, being careful not to perforate the cortex.

Figure 69-2 Classic technique for fibular groove deepening in the treatment of peroneal subluxation or dislocation.

Once the cortex has been weakened, a bone tamp is used to impact the posterior fibular cortex into the medullary canal. This can increase groove depth by 3 to 8 mm. The retinaculum is then closed in a pants-over-vest fashion.

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Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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