Review Question - QID 211990

This patient underwent a lateral ankle ligament reconstruction (modified Brostrum) and peroneus brevis debridement with tubularization. Due to the fact that the superior peroneal retinaculum (SPR) had to be released and repaired, resisted eversion should be avoided during early postoperative rehabilitation to allow anatomic healing. Failure of the retinaculum repair may result in tendon subluxation.

Residual lateral ankle instability following failed nonoperative management (such as bracing and compliance with a functional ankle rehabilitation program) may necessitate surgical intervention. A modified Brostrom lateral ankle ligament reconstruction, which involves imbrication of the anterior talofibular and calcaneofibular ligaments with advancement of the inferior extensor retinaculum, is most commonly employed. With the presence of a concomitant peroneal tendon tear, an extensile lateral approach is used to also address the peroneal pathology. In the setting of a 30% longitudinal split tear of peroneus brevis, debridement, repair, and tubularization is the treatment of choice. Tears of >50%, irreparable tears, or those with severe tendinopathy should be treated with tenodesis. In addressing peroneal pathology, incision of the superior peroneal retinaculum is necessary. Following its' repair, resisted eversion should be avoided during early postoperative rehabilitation because failure of the retinacular repair could result in subluxation of the peroneal tendons.

Maffulli et al. reviewed chronic lateral ankle instability following untreated acute lateral ankle ligament injuries. They report that failed nonsurgical management after appropriate rehabilitation is an indication for surgery, with anatomic repair of the ATFL and CFL being recommended. They concluded that anatomic reconstruction with autograft or allograft should be performed when the ruptured ligaments are attenuated, and tenodesis procedures are not recommended because they may disturb ankle and hindfoot biomechanics.

Philbin et al. reviewed peroneal tendon injuries in patients with chronic lateral ankle pain. They report that addressing concomitant peroneal tendons tears, subluxing or dislocating tendons, and peroneal tenosynovitis are of great importance in achieving a favorable outcome. They conclude that low-demand patients do well with a nonsurgical approach but high-demand patients may benefit from surgery.

Figure A is an intraoperative clinical imaging depicting a peroneal tendon tubulaization

Incorrect Answers:
Answers 2-5: With an SPR repair, resisted eversion should be avoided during early postoperative rehabilitation because failure of the retinacular repair could result in subluxation of the peroneal tendons