Peroneal tendon problems

Last evidence check and revision September 2009

Many different types of operation have been described to correct superior peroneal retinaculum (SPR) laxity:

Obviously, these are not all mutually exclusive. Our standard stabilisation procedure is an anatomical repair as described by Das De (1985, 1997) and Maffuli and Feran (2006). The retinaculum is opened longitudinally, close to where the attachment to the fibular groove should be. The bare area on the lateral malleolus is freshened and one or two suture anchors inserted close to the edge of the groove. The avulsed tissue sleeve is reattached to these and the retinaculum plicated, usually also onto the suture anchor(s). If the groove is shallow, a posterior trapdoor is elevated and cancellous bone removed from the posterior part of the lateral malleolus to allow the floor of the groove to be lowered and the edges of the trapdoor evened. Debridement and repair or tenodesis of tendon tears is usually required.

Das De and Subramanian described the anatomical repair in 1985 and in 1997 (Hui et al) reported 9-year results in 21 patients. There were no recurrences. 18/21 patients were satisfied and had returned to sport. Three patients had significant complications (2 painful scars, 1 nerve injury) and had not returned to sport. Maffuli and Feran reported 14 patients reviewed 3 years post-op. Mean AOFAS hindfoot score increased from 54 pre-op to 94 at review. There were no recurrent dislocations or other significant complications and 7/11 sportsmen returned to sport. Adachi et al (2006) reported 3-year follow-up of a similar procedure in 20 patients. Mean AOFAS hindfoot score improved from 76 pre-op to 93 at review. 15/18 sportsmen returned to sport. There were no recurrent dislocations or nerve injuries and no other complications were commented upon.

Peroneal groove deepening is intended to counteract the destabilising effects of a flat or convex posterior fibula. Edwards (1928, quoted in Kollias and Ferkel 1997) found a flat posterior fibula in 11% of dry fibulae and a convex surface in 7%. However, Saupe et al (2007) found a flat posterior fibula in 43%, and a convex surface in 18% of normal people at MRI, suggesting that the bony shape may be less important in creating instability and groove deepening less likely to be required to overcome it. Title et al (2005) showed that peroneal groove deepening reduced pressures in the distal part of the groove. It has been suggested that this might aid healing and symptom reduction. However, the reported results for groove deepening procedures (Zoellner and Clancy 1979, Kollias and Ferkel 1997, Porter et al 2005) are comparable with those of anatomical soft tissue repair alone.

All reports of stabilisation are small, usually 10-20 patients. Overall, about 85-90% of patients get satisfactory functional results from the vatious procedures, and some have returned to top-level sport. The rate of recurrent instability is 5-10%. Other complications include neuromas, infection and lateral ankle pain. There are no comparative trials, and the condition is sufficiently uncommon to make recruitment of adequate patient numbers difficult.

Symptomatic ankle instability can be corrected through the same incision, usually with a Brostrom-Gould procedure.