Letter to the Editor: Importance of Peroneal Fascia Closure in Peroneal Longus Graft Harvest

The peroneus longus graft (PLG) has long been used in the setting of various ligament surgeries as a reliable autograft. Its use in primary ACL surgery has garnered much attention in recent years. Proponents of its use argue that donor site morbidity is low after PL harvest, as has been shown by our recent systematic review and meta-analysis [1]. Critics raise concerns about its impact on ankle strength, gait patterns and eversion of the foot. A common stigma related to its use is the perception of ‘ankle and foot pain and swelling’ after PLG harvest.

At our high volume centre for PLG harvest, the early days of PLG usage were a learning curve. Part of this learning curve was the incidence of post-operative ankle swelling at (3–6) week follow-up which persisted for 3 months in approx. 10% of patients. Initially, we hypothesized that the swelling maybe secondary to dependent edema from our delayed weight bearing protocol post-ACL surgery, however, the initiation of venous pump on weight bearing should lead to immediate dissipation of symptoms.

In the search for answers, we examined our harvest technique and reviewed the anatomy of the PL [2, 3]. The peroneal longus and brevis are covered by their common investing fascia at the level of graft harvest site, approximately 2 cm above the tip of the fibula. It is here that we incise the fascia in a longitudinal manner to facilitate access to the peronei.

Incision of this fascia creates an effective dead space where post-operative bleeding will accumulate and lead to ankle swelling. We modified our technique to address this concern and now close the peroneal fascia at the time of layer closure with simple interrupted absorbable sutures. This seals the dead space and theoretically should reduce swelling even in a position of dependence. Since the last 2 years, we have been using this modification [4] and have found that the rate of post-operative swelling, with no change in our delayed weight bearing protocol, has come down significantly. We now see post-operative ankle swelling in less than 0.5% of our patients at the 6-week follow-up.

We believe that this simple step of peroneal fascia closure is important to reduce ankle site morbidity and should be a part of PLG harvest.