Is a C-arm (fluoroscopy machine) necessary for a right ankle ligament repair, peroneal tendon debridement, and tendon transfer?

C-arm Use in Right Ankle Ligament Repair, Peroneal Tendon Debridement, and Tendon Transfer

A C-arm (fluoroscopy) is not routinely necessary for right ankle ligament repair, peroneal tendon debridement, and tendon transfer procedures, as these are primarily soft tissue procedures that can be adequately visualized directly during surgery.

Imaging Considerations for Ankle Soft Tissue Procedures

Pre-operative Imaging

• MRI is the preferred imaging modality for evaluating ankle ligament and tendon injuries with excellent sensitivity (93%-96%) and specificity (100%) 1
• For peroneal tendon pathology, MRI has shown 83.9% sensitivity and 74.5% specificity for tendinopathy, and 54.5% and 88.7% for tendon tears 1
• Pre-operative planning should rely on these detailed imaging studies rather than intraoperative fluoroscopy

Intraoperative Visualization

• Ankle ligament repair and peroneal tendon procedures primarily involve soft tissue structures that can be directly visualized during surgery
• The American College of Radiology guidelines do not list fluoroscopy as a routine requirement for tendon abnormality evaluation or repair 1
• Fluoroscopy is specifically noted as "not routinely used for the evaluation of suspected tendon abnormality" 1

Procedure-Specific Considerations

Ankle Ligament Repair

• Lateral ankle ligament repairs (anterior talofibular and calcaneofibular ligaments) are performed through direct visualization
• The sensitivity (84%) and specificity (96%) of physical examination using the anterior drawer test are optimized with proper clinical assessment 1
• Direct visualization during surgery is sufficient for anatomic reconstruction

Peroneal Tendon Debridement

• Peroneal tendon debridement involves direct visualization of the damaged tendon tissue
• Long-term studies of peroneal tendon debridement and primary repair show excellent outcomes without mention of fluoroscopy requirement 2
• The procedure focuses on removing damaged tissue and repairing the remaining viable tendon

Tendon Transfer

• Tendon transfer procedures, such as flexor hallucis longus transfer for peroneal reconstruction, can be performed with direct visualization 3, 4
• The donor tendon harvest and recipient site preparation are primarily soft tissue procedures
• Case reports of complex ankle reconstructions involving peroneal tendon transfers do not specifically mention C-arm as essential 5

Exceptions When C-arm May Be Beneficial

While not routinely necessary, there are specific scenarios where C-arm fluoroscopy might be helpful:

• When bone tunnels are created for tendon fixation (to verify tunnel placement)
• If concurrent bony procedures are performed (osteotomy, fracture fixation)
• For verification of hardware placement if anchors or screws are used
• When anatomic landmarks are difficult to identify due to previous surgery or trauma

Conclusion

Based on the available evidence, ankle ligament repair, peroneal tendon debridement, and tendon transfer procedures do not routinely require C-arm fluoroscopy, as they primarily involve soft tissue structures that can be directly visualized during surgery. The American College of Radiology guidelines specifically note that fluoroscopy is not routinely used for evaluation of suspected tendon abnormality 1. Pre-operative MRI provides excellent visualization of the relevant anatomy, and intraoperative direct visualization is typically sufficient for these procedures.