Peroneal and Achilles tendon problems with surgical management

Peroneal tendon stabilisation

Anatomy Peroneal tendons course behind the distal fibula The peroneus brevis may have degenerative changes if the injury is not identified in a timely fashion

What happens and what you see The peroneal retinaculum may be avulsed from the fibula or calcaneus or lifted up enough to allow tendon dislocation Forceful contraction of peroneals during sudden dorsiflexion and inversion

Classification Figure Classification of pathology in peroneal tendon dislocations. A, Normal. B, Grade I: superior peroneal retinaculum stripped off fibula. C, Grade II: fibrous rim avulsed from the posterolateral aspect of the fibula along with the superior peroneal retinaculum. D, Grade III: bony avulsion of the posterolateral part of the fibula by the superior peroneal retinaculum. (Modified from Eckert WR, Davis EA Jr: J Bone Joint Surg Am 58: , 1976.)

Management 1 Direct repair If acute repair correctly Anchors useful to aid stabilisation of retinaculum

Management 2 Groove deepening repair Like trochleoplasty of the knee allowing a deeper grove for the tendons to sit in, minimising further dislocation Split the fibula distally leaving a posterior hinge intact, by curetting out some of the cancellous bone and replacing the hinge the groove will be deepened

Management 3 DuVries Bone block lateral fibula osteotomy procedure Creates new groove for tendons to sit in, posterior to the fibula Modification of Kelly procedure

Insertional Achilles tendinopathy

Approach to Achilles/Haglunds Can approach medially or laterally – If lateral find and protect the sural nerve Try and avoid central/splitting incision

Haglunds decompression I Try to remove degenerative tissue and decrease impingement Can take away more than you think

Haglunds decompression II Can resect/decompress with osteotome or burr. If involving greater than 50% of achilles stabilsie with anchors

FHL transfer Severe unremitting insertional tendinopathy Excessive calcific insertional tendinopathy Failed anchors resulting in pullout

Principles of FHL transfer 2 incisions: Medial over Achilles and Medial over knot of Henry Deliver FHL into Achilles wound and secure to OS Calsis with biotenodesis screw at appropriate tension NB don’t forget to tenodese distal FHL with FDL to enable flexion at big toe