Peroneal tendon surgery: repair, tenodesis and reconstruction

When surgery is considered

For background on the condition, see peroneal tendon injuries. Non-surgical treatment (immobilization, anti-inflammatory medicine, physical therapy and bracing) comes first.^[4] Surgery is generally considered when:

• pain, swelling or weakness persist despite that treatment
• a tendon is torn, especially when the tear is large or causes ongoing pain
• a tendon keeps slipping out of its groove behind the outer ankle bone
• you are a high-demand patient, such as an athlete, who wants to return to sport^[4,5,6]

The evidence supporting surgical choices comes mostly from case series and expert opinion, so the plan is individualized.^[3]

The main types of operation

The operation depends on the type of injury and the condition of the tendon.

• Tendon cleaning and repair. Damaged, frayed tissue is removed and the healthy tendon is stitched together. When a tendon is split, the surgeon may remove the damaged part and join what is left to the neighboring tendon (a tenodesis), so that one tendon protects the other.^[1]
• Tendon transfer or graft. When too little healthy tendon remains, a nearby tendon (the flexor digitorum longus or flexor hallucis longus) can be moved to take over the work, or a graft of donor tendon can be used to bridge the gap.^[1]
• Fixing a tendon that slips. The band of tissue that holds the tendons in the groove (the superior peroneal retinaculum) can be repaired or rebuilt. Some operations also deepen the groove, re-route the tendons, or reshape the bone.^[2]
• Treating the cause. A high-arched foot, ankle instability or a bony problem that overloads the tendon may need treatment at the same time, or the problem can return.^[3,7] See cavus foot and ankle ligament repair and reconstruction.

What do the results show?

• Tears. A systematic review of nine studies and 336 ankles evaluated five approaches: repair with a tenodesis, repair without a tenodesis, transfer of the flexor digitorum longus, transfer of the flexor hallucis longus, and allograft reconstruction. Average function scores rose from about 70 to about 89 out of 100, and pain scores fell from about 4.7 to 1.2 out of 10. Repair without a tenodesis had a higher complication rate than the others.^[1]
• Tendon instability. A review of 31 studies compared retinaculum repair, groove deepening, re-routing and bone procedures. All improved function. Bone procedures had less satisfying results, and re-routing and bone procedures had higher complication rates. The chance of the tendon slipping out again did not differ significantly, and the studies were of variable quality.^[2]

Recovery

Recovery depends on the operation. A typical plan is a period in a splint, cast or boot without or with limited weight on the foot, then a gradual return to weight-bearing and motion, followed by physical therapy to restore strength, balance and confidence in the ankle. The details vary between surgeons and procedures, and your surgeon will give you a timetable. Return to sport generally takes months. See recovery after foot and ankle surgery and preparing for foot and ankle surgery.

Risks

Risks include infection, wound-healing problems, stiffness, ongoing outer ankle pain, injury or irritation of a nearby nerve, a repeat tear or slipping of the tendon, and the general risks of surgery, including blood clots. In the systematic review of tears, about 39% of patients had some complication, most commonly minor ankle pain.^[1] Higher rates were reported for re-routing and bone procedures in tendon instability.^[2]

Questions to ask before deciding

• Is the tendon torn, and if so, how much is left to repair?
• Would you repair, transfer or graft, and why?
• Does anything else, such as a high arch or loose ligaments, need to be treated at the same time?
• When can I walk on the ankle, drive, and return to work and sport?

When to seek care