Rationale
Acute peroneal tendon dislocation typically occurs after a forced eccentric contraction of the peroneal muscles combined with dorsiflexion and eversion of the ankle [
29]. Multiple management options have been proposed for the treatment of peroneal dislocations, generally aiming to repair or reconstruct the SPR, correct predisposing factors and increase the volume of the peroneal tunnel. While the benefits of surgery have been shown in the literature [
44], the value of conservative management remains unclear. The current evidence is limited to a number of case reports and small retrospective series suggesting that the risk of recurrent peroneal instability is approximately 50% [
21]. As discussed in the section “Classification and Terminology”, the panel determined that choosing optimal treatment necessitates differentiation between acute and chronic injury and between the athlete and non-athlete population.
For acute instability in non-athletes, the panel agreed that both conservative and surgical management are indicated. Although conservative management carries a 50% risk of failure, secondary surgical treatment does not lead to a worse prognosis or alter the surgical options available if it fails. Conservative management should include immobilization in a cast in slight plantarflexion or in a boot with a 2 cm heel wedge for six weeks. If, however, the patient has a suspected or confirmed anterior talofibular ligament injury, they should be immobilized in a neutral position to not compromise the lateral ligament healing. Physical therapy is commenced after six weeks with peroneal strengthening and ankle proprioception exercise.
Surgery in non-athletes with acute peroneal instability consists of reduction of the tendons into the retrofibular groove and repair of the SPR. There was no consensus as to whether an additional groove deepening procedure was required in open repairs. In addition, no agreement was reached as to whether endoscopic or open treatment was favoured, but it was agreed that either was acceptable with the acknowledgement that endoscopic treatment may have less potential complications and allows for earlier functional rehabilitation. If endoscopic stabilization is performed, the panel agreed that the most appropriate technique is to debride the lateral edge of the fibula, where the retinaculum has been lifted away, followed by groove deepening. The SPR does not require formal repair; however, this option is valid.
In the athlete with acute instability, conservative management is not advised and early surgical stabilization is the treatment of choice. Opposing to the non-athlete population, the panel agreed that, for this group, surgery should include deepening of the retromalleolar groove. There was agreement that both endoscopic and open treatment are accurate surgical modalities. As stated above, however, endoscopic treatment may allow earlier functional rehabilitation, which may allow earlier return to play.
In chronic injuries, the panel recommended surgical stabilization as the first line treatment with deepening of the retromalleolar groove. In chronic injuries, shortening of the tendons is often seen and groove deepening allows for accommodation of this and greater stability. There was no favour as to the choice of endoscopic or open treatment.
In all types of peroneal instability, there was agreement that in open stabilization, the SPR should always be repaired, but extra care should be taken not to over tighten the SPR, which could result in stenosis of the retromalleolar space. It was also recommended to treat potential tunnel overcrowding factors such as a LLMB or an accessory muscle.