I broke my fibula in half and tore two different tendons. What is the treatment for the torn tendons?
Answers
CLINICAL PRESENTATION
The typical patient describes recurrent lateral instability of the ankle joint as the primary problem. In addition, retromalleolar pain combined with recurrent giving way is typical. The pain is almost always localized posterior to the lateral malleolus. This is in contrast to patients with chronic lateral ankle instability alone, who usually mention giving way as the main complaint and anterior ankle pain as a secondary problem, most frequently caused by anterior tibial or talar osteophytes or loose intra-articular bodies (bone or cartilage). A thorough physical examination includes an assessment of ligament integrity (ie, positive anterior drawer test or increased supination of the foot suggests injury). An assessment of range of motion is mandatory. Palpable swelling around and behind the lateral malleolus can raise the suspicion of a tendon tear.
RADIOGRAPHIC EVALUATION
There is a substantial risk of delayed or missed diagnosis with PBT tear. Either magnetic resonance imaging (Figure (Figure2)2) or ultrasound imaging is recommended to increase the diagnostic accuracy in these patients.
Figure 2
Figure 2
Sagittal oblique spin-echo proton density-weighted magnetic resonance image showing high signal intensity within the peroneus brevis tendon at the lateral malleolar level (black arrow). The peroneus longus tendon (white arrow) is normal.
TREATMENT
One constant finding at surgery is the subluxation of the anterior half of the PBT over the sharp posterior edge of the fibula. Moreover, the SPR is partially torn away from the posterior ridge of the fibula. Some authors5 have mentioned that this lesion resembles a Bankart lesion in recurrent anterior dislocation of the shoulder. Recurrent dislocation of the peroneal tendons is, however, not a primary problem.24 If concomitant lateral ankle instability is present, the consensus in the literature is that the tendon injury should be repaired at the same time as the ligament stabilization. Only a few reports on surgical treatment have been published, and we found no large series. Sobel and Geppert14 recommended a modification of the Broström-Gould procedure25 for the treatment of concomitant lateral ankle instability and PBT tear using a posterolateral approach.
A modified Chrisman-Snook procedure has been suggested by some researchers.8,24 The largest series is described by Bonnin et al,17 who operated on 18 patients with split lesions of the PBT associated with chronic ankle instability. During a 3-year period, 18 of 77 patients (23%) with chronic ankle-ligament laxity who underwent surgical repair had a concomitant PBT tear. The modfied Chrisman-Snook procedure was used in 13 of 18 patients studied. Regrettably, the clinical results were not described in detail in this report, making it impossible to draw any conclusions in terms of the choice of treatment. One potential problem when using this procedure is fraying of the tendon, making repair technically impossible.
In several reports,5,26 the anatomical reconstruction of the lateral ankle ligaments has been described as simple and safe, producing stable ankles with a low risk of complications in most patients. This procedure can be combined with the reconstruction of the SPR (Figures (Figures33,,44,,5).5). The operation begins with a curvilinear 7- to 8-cm long incision along the posterior ridge of the fibula, exposing the peroneal tendons and the anterior talofibular and calcaneofibular ligaments. The ligaments are tested for laxity, and the SPR is exposed. The peroneal tendon sheath is incised approximately 5 mm posterior to the attachment to the fibula. Then the PBT is carefully examined. The degenerative tissue is carefully excised, and the tendon is repaired with side-to-side sutures. In some cases, the ruptured anterior part of the tendon may have to be excised; however, this is infrequent, and complete rupture of the PBT is extremely uncommon. A reconstruction of the SPR is performed, using three 2.0-mm drill holes in the posterior aspect of the fibular edge. Because insufficiency of the lateral ligaments is usually present, anatomical reconstruction of both the anterior talofibular and calcaneofibular ligaments is performed.