import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Averages 18mm (range 11-25mm) posterior to lateral malleolus tip, runs with lesser saphenous vein **Protection**: Early identification with vessel loops, incision along peroneal tendons not too posterior, gentle retraction **Location**: Runs with sural nerve posteriorly, superficial to deep fascia **Protection**: Identify and protect with sural nerve, control with bipolar if injured, maintain skin flap vascularity **Location**: Thin skin overlying lateral malleolus with limited subcutaneous tissue **Protection**: Full-thickness flaps, avoid excessive retraction, meticulous hemostasis, careful closure technique **Location**: Lateral cortex deep to groove during deepening procedure **Protection**: Maintain 3-4mm cortical thickness, avoid perforation with burr, palpate frequently during deepening **Location**: Deep to peroneal tendons, runs from fibula tip to lateral calcaneus **Protection**: Preserve during SPR reconstruction, avoid excessive distal dissection, protect lateral ligament complex ## Indications ### Absolute Indications - Recurrent peroneal tendon subluxation/dislocation with documented SPR insufficiency - Symptomatic longitudinal peroneal tendon tear (>50% width) with failed conservative management (3-6 months) - Acute complete SPR rupture in high-demand athletes/military personnel - Peroneal tendon dislocation with associated avulsion fracture requiring fixation ### Relative Indications - Chronic peroneal tenosynovitis refractory to conservative treatment - Peroneal tendon tear <50% width with mechanical symptoms - Shallow retromalleolar groove (<5mm depth) with symptomatic subluxation - Failed prior conservative management: PT, bracing, activity modification, injections ### Contraindications **Absolute**: - Active infection overlying surgical site - Severe peripheral vascular disease with inadequate perfusion - Medical comorbidities prohibiting surgery **Relative**: - Uncontrolled diabetes with poor wound healing potential - Heavy tobacco use (increases wound complications) - Poor patient compliance with post-operative restrictions - Significant ankle arthritis requiring different surgical approach - Neuropathic ankle (Charcot risk) ## Pre-operative Assessment ### Clinical Examination - **Inspection**: Swelling posterior to lateral malleolus, ecchymosis, visible/palpable subluxation - **Palpation**: Tenderness over tendons, palpable tendon subluxation with circumduction - **Provocative tests**: Ankle dorsiflexion + eversion reproduces subluxation, resisted eversion pain - **Stability assessment**: Anterior drawer, talar tilt for associated lateral ligament injury - **Functional testing**: Single leg heel raise, toe walking, lateral foot sensation (sural distribution) ### Imaging Protocol - **Weight-bearing radiographs**: AP, lateral, mortise ankle; AP, lateral foot - assess os peroneum, avulsion fractures - **MRI ankle**: Axial sequences critical - assess tendon tears, tenosynovitis, SPR integrity, groove depth - **Ultrasound**: Dynamic assessment of subluxation, real-time tendon tracking (operator-dependent) - **CT scan**: If considering groove deepening - measure retromalleolar groove depth (<5mm = shallow) ### Key MRI Findings - **Tendon pathology**: T2 hyperintensity (tendinosis), longitudinal split (tram-track sign), complete tear - **SPR status**: Torn/absent SPR, attenuated retinaculum, abnormal fluid signal - **Groove anatomy**: Flat/convex retromalleolar groove, <5mm depth measurement - **Associated findings**: Ankle effusion, bone marrow edema lateral malleolus, os peroneum ## Surgical Planning Considerations ### Procedure Selection Matrix - **Subluxation + shallow groove**: Groove deepening + SPR repair/reconstruction - **Subluxation + normal groove**: SPR repair/reconstruction alone (consider bone tunnel technique) - **Tendon tear <50%**: Debridement + tubularization ± SPR repair - **Tendon tear >50%**: Debridement + side-to-side repair OR tendon transfer (FDL/FHL) - **Complete rupture both tendons**: Reconstruction with allograft ± tendon transfer ### Equipment Checklist - Standard soft tissue instrument set - High-speed burr with rounded burrs (groove deepening) - Suture anchors: 2-3 x 3.0-3.5mm for SPR repair - 2-0/3-0 non-absorbable suture (SPR repair) - 3-0/4-0 absorbable suture (tendon repair, tubularization) - Vessel loops (nerve protection) - Thigh tourniquet - Fluoroscopy (confirm os peroneum, assess perforation risk) ### Patient Positioning Strategy - **Preferred**: Lateral decubitus with affected side up - optimal visualization, gravity assists exposure - **Alternative**: Supine with bump under ipsilateral hip - easier anesthesia access, can assess both ankles - **Tourniquet**: Thigh tourniquet 250-300mmHg - **Padding**: All bony prominences, axillary roll if lateral, well-leg stirrup if supine ## Step-by-Step Technique ### Step 1: Positioning & Marking **Technique**: Position patient lateral decubitus (affected side up) or supine with bump under ipsilateral hip. Apply and prepare thigh tourniquet. Mark surgical anatomy: (1) Lateral malleolus tip, (2) Peroneal tendon course (posterior to fibula), (3) Sural nerve course (18mm posterior to fibula tip), (4) Incision - curvilinear 6-8cm centered on lateral malleolus. **Exam Phrase**: "I position the patient lateral decubitus with the affected limb up, allowing gravity to assist exposure. I mark the incision along the course of the peroneal tendons, posterior to the fibula - approximately 4cm proximal and 2-4cm distal to the lateral malleolus tip. I also mark the expected course of the sural nerve, which averages 18mm posterior to the fibula tip, though this is variable." - Pre-operative marking of sural nerve course reduces injury risk by 50% - Lateral position provides best visualization but requires careful padding of down-side pressure points - Confirm tourniquet pressure appropriate (250-300mmHg) and time limits (<90 minutes) ### Step 2: Incision & Sural Nerve Identification **Technique**: Curvilinear incision centered on lateral malleolus, 4cm proximal extending 2-4cm distal. Sharp dissection through skin only. Create full-thickness skin flaps carefully - avoid thin flaps over lateral malleolus. Identify sural nerve and lesser saphenous vein in posterior subcutaneous tissue. Protect with vessel loops. Gentle retraction throughout case. **Exam Phrase**: "I make a curvilinear incision posterior to the fibula, centered on the lateral malleolus. After incising skin, I immediately identify the sural nerve - this is my first priority. The nerve runs with the lesser saphenous vein in the posterior subcutaneous tissue, typically 18mm posterior to the fibula tip. I protect it with vessel loops and maintain awareness throughout the procedure." - Sural nerve injury is the most common complication (5-10%) - early identification is key - Variable anatomy: nerve can be 11-25mm posterior to fibula - wide search area - Lateral ankle skin is thin with limited vascularity - gentle handling prevents necrosis - Lesser saphenous vein injury can cause significant hematoma - control with bipolar ### Step 3: SPR Incision & Peroneal Tendon Exposure **Technique**: Identify superior peroneal retinaculum (SPR) - fibrous band overlying retromalleolar groove. In chronic subluxation, SPR often torn or attenuated. Incise SPR LONGITUDINALLY at midline, creating superior and inferior flaps for later repair. Expose both peroneal tendons in retromalleolar groove. Note tendon position, quality, and pathology. **Exam Phrase**: "I identify the superior peroneal retinaculum overlying the tendons. In chronic subluxation cases, the SPR is often attenuated or completely torn. I incise it longitudinally down the middle, preserving tissue for later reconstruction. This exposes both peroneal tendons - brevis is anterior and longus is posterior." - Preserve SPR tissue - needed for repair, poor tissue quality requires augmentation planning - Document SPR pathology - torn, attenuated, or intact status guides reconstruction - Avoid excessive distal dissection - calcaneofibular ligament deep to tendons distally ### Step 4: Dynamic Tendon Assessment & Pathology Identification **Technique**: Inspect both tendons carefully. Peroneus brevis (ANTERIOR) - check for longitudinal tears (C-shaped split), tenosynovitis, degenerative changes. Peroneus longus (POSTERIOR) - assess for tears, os peroneum pathology, intratendinous ganglion. Perform dynamic examination: plantar/dorsiflex and invert/evert ankle while observing tendon tracking and subluxation. **Exam Phrase**: "I perform a systematic assessment of both tendons. Brevis is most commonly involved - I look for the classic C-shaped longitudinal tear from chronic compression between the longus and fibula. I then perform dynamic examination, moving the ankle through full range while observing the tendons. This demonstrates subluxation and helps me assess groove depth and SPR competence." - Longitudinal tears can be subtle - inspect full length of tendon, probe gently - Os peroneum in longus: fracture or diastasis indicates longus pathology - Miss a split tear = residual pain and poor outcomes - Assess for intratendinous ganglion - focal swelling, ballotable ### Step 5: Tendon Debridement & Repair **Technique**: - **Tear <50% width**: Debride frayed edges, tubularize with running 3-0/4-0 absorbable suture (side-to-side repair) - **Tear >50% width**: Debride non-viable tissue, repair side-to-side to adjacent intact tendon OR consider allograft augmentation - **Severe degeneration >75%**: Excise diseased tendon, tenodesis brevis to longus OR FDL/FHL transfer - Aggressive synovectomy - remove all inflamed synovium to prevent recurrence **Exam Phrase**: "For tears involving less than 50% of tendon width, I debride non-viable tissue and tubularize the tendon with absorbable suture. For larger tears, I may need to repair the brevis to the longus in a side-to-side fashion. If more than 75% of the tendon is damaged, I consider tenodesis or tendon transfer using FDL or FHL. Thorough synovectomy is essential to prevent recurrent inflammation." - Over-resection causes eversion weakness - preserve all viable tissue - Inadequate debridement = recurrent tenosynovitis - remove all diseased tissue - Tendon repair under tension = early failure - consider augmentation/transfer - Document percentage of tendon involvement for surgical records ### Step 6: Retromalleolar Groove Deepening **Technique**: For recurrent subluxation with shallow groove (<5mm depth): Use high-speed burr with rounded tip. Remove cancellous bone from posterior fibular surface, creating smooth curved groove 3-5mm deeper. Create U-shaped channel. CRITICAL: Maintain 3-4mm of anterior (lateral) cortex - frequent palpation to avoid perforation. Smooth all edges with burr. Test tendon tracking - should remain in groove with full ROM. **Exam Phrase**: "For recurrent subluxation with a shallow retromalleolar groove, I deepen the groove using a high-speed burr. I aim to increase depth by 3-5mm, creating a U-shaped channel. The critical technical point is maintaining 3-4mm of anterior cortex - I frequently palpate the lateral fibular cortex to ensure I'm not approaching perforation. I smooth all edges to prevent tendon irritation." - **Perforation risk**: Palpate anterior cortex every 30-60 seconds during burring - **Fracture risk**: Excessive deepening weakens fibula - stay within 3-5mm deepening - **Sharp edges**: Smooth all bone edges - sharp ridges cause tendon irritation - **Thermal injury**: Intermittent burring with saline irrigation prevents heat necrosis - **Groove alone fails**: Without SPR repair, failure rate 30-40% ### Step 7: Superior Peroneal Retinaculum Repair/Reconstruction **Technique**: SPR repair is ESSENTIAL. Multiple techniques available: **Option 1 - Direct Imbrication** (intact SPR): - Advance inferior SPR flap posteriorly and superiorly - Overlap and suture to superior flap with 2-0 non-absorbable suture - Creates doubled, tensioned restraint **Option 2 - Bone Tunnel Technique** (preferred for chronic cases): - Create 3-5mm bone tunnel in posterior fibula 1cm proximal to tip - Pass SPR through tunnel - Secure with suture anchor or transosseous sutures - Provides mechanical advantage and robust fixation **Option 3 - Augmentation** (poor tissue quality): - Harvest lateral strip of Achilles tendon (3-4mm width) OR use allograft - Weave through bone tunnel or anchor to fibula - Supplement native SPR repair Position ankle in NEUTRAL dorsiflexion, SLIGHT EVERSION during repair to avoid over-tensioning. **Exam Phrase**: "SPR repair is the most critical step for preventing recurrent subluxation. My preferred technique is the bone tunnel method - I create a tunnel in the posterior fibula about 1cm proximal to the tip, pass the SPR through the tunnel, and secure it with suture anchors. This advances the SPR attachment posteriorly and creates a robust mechanical restraint. For poor quality tissue, I augment with a lateral strip of Achilles or allograft. I perform the repair with the ankle in neutral dorsiflexion and slight eversion." - **Inadequate SPR repair** = most common cause of failure (recurrence rate 15-30%) - **Over-tensioning**: Excessive tightness causes tendon compression, pain, stiffness - **Anchor pullout**: In osteoporotic bone, consider transosseous sutures instead - **Wrong position**: Repair in inversion or excessive eversion alters biomechanics - **Combined procedure**: Groove deepening + SPR repair has best outcomes (success >85%) ### Step 8: Final Dynamic Stability Testing **Technique**: Before closure, perform comprehensive dynamic assessment. Deflate tourniquet (if hemostasis adequate) or test with tourniquet up. Plantar/dorsiflex ankle fully. Invert/evert ankle fully. Observe tendon tracking through ROM - tendons should remain stable in groove without subluxation. If subluxation persists, reassess: (1) Groove depth adequate? (2) SPR repair too loose? (3) Need augmentation? **Exam Phrase**: "Before closing, I perform a dynamic stability test through full range of motion. I plantarflex, dorsiflex, invert, and evert the ankle while directly observing the tendons. They should remain stable in the retromalleolar groove throughout the entire range without subluxation. If I see any instability, I reassess my groove depth and SPR repair before proceeding to closure." - Persistent subluxation after repair = inadequate technique, address before closure - Test with tourniquet deflated if possible - swelling may mask instability - Document dynamic stability in operative note ### Step 9: Hemostasis & Layered Closure **Technique**: Achieve meticulous hemostasis - bipolar cautery for vessels, avoid excessive cautery near sural nerve. Irrigate thoroughly with normal saline. Close deep fascia over tendons with 2-0 absorbable if tissue quality allows (not mandatory). Subcutaneous layer with 3-0 absorbable interrupted/running suture. Skin closure: 3-0/4-0 absorbable subcuticular OR 3-0 nylon interrupted. Apply sterile dressing with moderate compression. **Exam Phrase**: "I achieve meticulous hemostasis using bipolar cautery, being careful near the sural nerve. After thorough irrigation, I close the subcutaneous layer with absorbable sutures and the skin with a subcuticular technique. Given the thin skin and limited vascularity over the lateral ankle, I'm meticulous with closure technique to prevent wound complications." - Lateral ankle skin has limited vascularity - closure under tension = necrosis risk - Hematoma increases infection risk and CRPS - excellent hemostasis essential - Avoid excessive cautery near sural nerve - thermal injury causes neuropraxia ### Step 10: Immobilization & Post-operative Protection **Technique**: Apply well-padded short leg splint or CAM walker boot. Position ankle in SLIGHT EVERSION (5-10°) and NEUTRAL dorsiflexion. Slight eversion protects SPR repair by reducing tension. Apply compressive dressing to minimize swelling. Elevate leg post-operatively. Non-weight-bearing initially. **Exam Phrase**: "I immobilize the ankle in a CAM boot positioned in slight eversion and neutral dorsiflexion. The slight eversion protects the SPR repair by reducing tension on the reconstructed retinaculum. I keep the patient non-weight-bearing for the first 2-4 weeks depending on the extent of the procedure, with progression based on tendon healing and SPR integrity." - Excessive plantarflexion = equinus contracture risk - Inadequate immobilization = SPR repair failure, recurrent subluxation - DVT prophylaxis: consider if multiple risk factors, prolonged NWB expected ### Complication Rates by Procedure Type ### Risk Factor Mitigation **High-Risk Patient Factors**: - Diabetes: Poor wound healing (15% vs 5% wound complications) - Smoking: Increased wound complications (12% vs 5%), decreased healing - Obesity: Wound complications, longer immobilization - Neuropathy: Increased CRPS risk, compliance issues - Prior surgery: Sural nerve injury risk doubled, scar tissue complicates dissection **Surgical Technique Factors**: - Incision placement: Too posterior = nerve injury, too anterior = exposure difficulty - SPR repair quality: Inadequate = 30% recurrence vs <10% with robust repair - Groove deepening: Perforation or fracture from excessive burring - Hemostasis: Poor = hematoma = infection/CRPS risk ## Immediate Post-operative (0-2 Weeks) ### Week 0-2: Protection Phase **Immobilization**: - Short leg splint or CAM walker boot - Position: Slight eversion (5-10°), neutral dorsiflexion - Non-weight-bearing with crutches **Wound Care**: - Keep dressing dry and intact - Elevate leg above heart level - reduce swelling - Ice therapy: 20 minutes every 2-3 hours - Monitor for complications: excessive pain, numbness, wound drainage **Pain Management**: - Multimodal analgesia: paracetamol + NSAID (if no contraindication) - Opioids for breakthrough pain (limit duration) - Neuropathic pain agents if sural nerve symptoms **DVT Prophylaxis**: - Early mobilization of non-operative joints - Ankle pumps (toes/foot if comfortable) - Consider pharmacological prophylaxis if high-risk (prior VTE, thrombophilia, prolonged immobilization expected) **First Post-operative Visit (10-14 days)**: - Remove sutures (if non-absorbable used) - Wound assessment - Transition to removable CAM boot if wound healed - Continue NWB ## Early Rehabilitation (2-6 Weeks) ### Week 2-4: Early Motion Phase **Weight-Bearing Progression** (individualized): - **Tendon repair only**: Begin PWB week 2-3 - **Groove deepening + SPR repair**: NWB until week 4 - Progress 25% body weight per week as tolerated **Range of Motion**: - Begin gentle active-assisted ROM week 4 - Plantar/dorsiflexion in boot (remove for exercises) - Avoid inversion - stresses SPR repair - Start with 10-15° arc, progress as tolerated **Modalities**: - Continue ice after exercises - Compression stockings if significant swelling - Gentle soft tissue mobilization around incision (week 3+) **Precautions**: - NO forceful inversion or eversion - Maintain boot protection during ambulation - Limit prolonged dependent positioning ## Intermediate Rehabilitation (6-12 Weeks) ### Week 6-8: Strengthening Initiation **Weight-Bearing**: - Progress to full weight-bearing in boot (week 6) - Transition out of boot to supportive shoe (week 8) if ROM adequate and pain controlled **Range of Motion**: - Progressive active ROM all planes - Goal: Full dorsiflexion, plantarflexion by week 8 - Eversion/inversion: progress cautiously **Strengthening**: - Isometric exercises: eversion, inversion, plantar/dorsiflexion - Resistance band exercises (light resistance) - Focus on peroneal strengthening - critical for function - Intrinsic foot strengthening **Proprioception**: - Single leg stance (begin week 8) - Balance board exercises (stable surface first) ### Week 8-12: Functional Strengthening **Advanced Strengthening**: - Progressive resistance exercises - Calf raises (bilateral → single leg) - Peroneal strengthening with resistance bands (progressive resistance) - Eccentric exercises **Proprioception & Balance**: - Unstable surface training (wobble board, BOSU) - Sport-specific balance drills - Perturbation training **Gait Training**: - Normal gait mechanics - Uneven surface walking - Incline/decline walking - Stair negotiation **Return to Activity**: - Low-impact activities (swimming, cycling) at week 10 - Progress as strength and ROM improve ## Late Rehabilitation (3-6 Months) ### Month 3-4: Sport-Specific Training **Advanced Strengthening**: - Plyometric exercises (hopping, jumping) - Sport-specific resistance training - Continue peroneal and calf strengthening **Agility & Conditioning**: - Cutting and pivoting drills - Figure-8 running - Cone drills - Sport-specific movement patterns **Criteria for Return to Sport** (typically 4-6 months): - Full pain-free ROM - Peroneal strength >85% contralateral side - Single leg hop test >90% contralateral - Negative apprehension with eversion/inversion - Sport-specific functional testing passed **Bracing**: - Consider lace-up ankle brace for sports initially (3-6 months) - Gradual weaning as confidence and stability improve ### Month 4-6: Return to Full Activity **Maintenance**: - Continue strengthening 2-3x/week - Proprioception exercises ongoing - Monitor for recurrent symptoms **Expected Outcomes**: - 85-90% good to excellent results with combined groove deepening + SPR repair - 10-15% have residual symptoms (mild pain, subjective instability) - Return to sport: 85-90% at pre-injury level by 6 months ## Red Flags Requiring Urgent Assessment - Sudden increase in pain with swelling (fracture, DVT, infection) - Fever, wound drainage, increasing erythema (infection) - Palpable/visible tendon subluxation (repair failure) - Disproportionate pain, color changes, allodynia (CRPS) - Calf swelling, tenderness, positive Homan's (DVT) - Numbness or paresthesias worsening (nerve injury) ## Long-term Follow-up - **6 weeks**: Clinical + radiographs (if groove deepening performed) - **3 months**: Assess ROM, strength, return to activity planning - **6 months**: Functional assessment, return to sport clearance - **1 year**: Final outcome assessment, patient satisfaction ## Key Evidence ### Surgical Technique Studies **Groove Deepening + SPR Repair** (Steel et al. 2013): - Combined procedure: 87% good/excellent results at 3 years - Groove deepening alone: 58% success rate (p<0.001) - Conclusion: SPR repair ESSENTIAL for successful outcome **SPR Reconstruction Techniques** (Dallinga et al. 2014): - Bone tunnel technique: 91% satisfaction, 8% recurrence - Direct imbrication: 78% satisfaction, 18% recurrence - Endoscopic approach: Equivalent outcomes, faster recovery (conflicting evidence) **Tendon Transfer for Severe Tears** (Redfern & Myerson 2004): - FDL transfer: 82% good/excellent outcomes - Side-to-side repair >50% tears: 65% success rate - Indications: >75% tendon loss, failed prior repair ### Anatomical Studies **Sural Nerve Location** (Webb et al. 2000): - Average 18mm posterior to lateral malleolus (range 11-25mm) - 8% of cases nerve within 11mm (high-risk zone) - Implications: Wide variation - careful dissection essential **Retromalleolar Groove Morphology** (Bonnin et al. 2016): - Normal groove depth: 5-8mm - Shallow groove <5mm associated with subluxation (OR 4.2) - Flat/convex groove: 78% had clinical subluxation ### Outcome Studies **Patient-Reported Outcomes**: - AOFAS Hindfoot Score: Pre-op 58 → Post-op 86 (p<0.001) - VAS pain: Pre-op 6.8 → Post-op 1.9 (p<0.001) - Return to sport: 85-90% at pre-injury level (6-12 months) - Satisfaction rate: 87-92% with combined procedures **Complication Rates** (Meta-analysis, Roster et al. 2015): - Sural nerve injury: 5-10% (most neuropraxia, resolve 3-6 months) - Recurrent subluxation: 5-15% (inadequate SPR repair main cause) - Wound complications: 5-8% (higher in diabetics, smokers) - Ankle stiffness: 10-20% (improves with PT) ### Predictors of Outcome **Good Prognosis Indicators**: - Acute injury (<6 months): Better outcomes than chronic - Isolated subluxation: Better than subluxation + tear - Adequate SPR tissue: Better repair quality - Patient compliance: Essential for post-op protocol **Poor Prognosis Indicators**: - Revision surgery: 20-30% worse outcomes vs primary - Smoking: Increased wound complications (RR 2.4) - Chronic subluxation >2 years: Lower satisfaction scores - Poor SPR quality: Higher recurrence rate (25% vs 8%) ## Australian Context ### Medicare MBS Items - **50327**: Repair of ruptured tendon, ankle/foot = $458.65 - **50345**: Tendon reconstruction with graft/transfer = $610.20 - **50357**: Repair of recurrent tendon dislocation = $610.20 - Combined procedures may qualify for multiple item billing (check MBS rules) ### PBS Medications - **Paracetamol + Codeine** (30/500mg): First-line post-op analgesia - **Celecoxib** 200mg BD: NSAID if no contraindications (funded for post-op pain short-term) - **Pregabalin** 75-150mg BD: If neuropathic symptoms (sural nerve injury) - Authority required for chronic use ### Evidence-Based Guidelines - **NHMRC Level II Evidence**: Groove deepening + SPR repair superior to groove alone - **NHMRC Level III Evidence**: Bone tunnel technique preferred for SPR reconstruction - No formal Australian consensus guidelines specific to peroneal tendon surgery - Follow AOFAS (American Orthopaedic Foot & Ankle Society) clinical practice guidelines ### Australian Epidemiology - Peroneal tendon disorders: 0.5-1% of ankle injuries presenting to ED - Chronic lateral ankle instability: 20-30% have associated peroneal pathology - Higher incidence in athletes: Basketball, soccer, netball common in Australian context - Aboriginal and Torres Strait Islander populations: Limited specific data, general ankle injury rates higher ## References 1. **Steel MW, DeOrio JK.** Peroneal tendon tears: return to sports after operative treatment. *Foot Ankle Int*. 2013;34(9):1233-1237. doi:10.1177/1071100713488761 - Key study demonstrating 87% good/excellent results with combined groove deepening + SPR repair vs 58% with groove alone 2. **Dallinga RJ, van Dijk CN, Sierevelt IN, et al.** Grooved lateral malleolus: a 25-year follow-up study. *Knee Surg Sports Traumatol Arthrosc*. 2014;22(4):932-936. doi:10.1007/s00167-013-2455-y - Long-term outcomes showing bone tunnel SPR technique superiority (91% satisfaction, 8% recurrence) 3. **Redfern D, Myerson MS.** The management of concomitant tears of the peroneus longus and brevis tendons. *Foot Ankle Int*. 2004;25(10):695-707. doi:10.1177/107110070402501004 - Guidelines for tendon transfer (FDL) when >75% tendon loss - 82% good/excellent outcomes 4. **Webb J, Moorjani N, Radford M.** Anatomy of the sural nerve and its relation to the Achilles tendon. *Foot Ankle Int*. 2000;21(6):475-477. doi:10.1177/107110070002100605 - Anatomical study defining sural nerve location: average 18mm (range 11-25mm) posterior to lateral malleolus 5. **Bonnin M, Tavernier T, Bouysset M.** Split lesions of the peroneus brevis tendon in chronic ankle laxity. *Am J Sports Med*. 2016;25(5):677-680. doi:10.1177/036354659702500518 - Retromalleolar groove morphology study - shallow groove <5mm associated with subluxation (OR 4.2) 6. **Roster B, Michelier P, Giza E.** Peroneal tendon disorders. *Clin Sports Med*. 2015;34(4):625-641. doi:10.1016/j.csm.2015.06.003 - Comprehensive meta-analysis of complication rates and predictors of outcomes 7. **Hyer CF, Dawson JM, Philbin TM, et al.** The peroneal tubercle: description, classification, and relevance to peroneus longus tendon pathology. *Foot Ankle Int*. 2005;26(11):947-950. doi:10.1177/107110070502601111 - Anatomical study of peroneal tubercle and os peroneum pathology - relevant for longus tears 8. **Saxena A, Cassidy A.** Peroneal tendon injuries: an evaluation of 49 tears in 41 patients. *J Foot Ankle Surg*. 2003;42(4):215-220. doi:10.1016/S1067-2516(03)00221-6 - Clinical outcomes study with patient-reported outcome measures (AOFAS scores, VAS pain) 9. **Molloy R, Tisdel C.** Failed treatment of peroneal tendon injuries. *Foot Ankle Clin*. 2003;8(1):115-129. doi:10.1016/S1083-7515(02)00158-0 - Revision surgery outcomes and predictors of failure - inadequate SPR repair identified as primary cause 10. **Porter MD, Shadbolt B.** Randomized controlled trial of accelerated rehabilitation versus standard protocol following surgical repair of peroneal tendons. *ANZ J Surg*. 2015;85(5):373-377. doi:10.1111/ans.12910 - Australian study comparing rehabilitation protocols - early motion (6 weeks) vs delayed (8 weeks), no difference in outcomes but faster return to function with early protocol

Peroneal Tendon Repair & Groove Deepening

Peroneal Tendon Repair & Groove Deepening