Effects of Peroneal Tendon Pathologies in 311 Patients Who Underwent Arthroscopic Repair for Lateral Instability of the Ankle

Abstract

Introduction: Few reports described the effects and clinical outcomes of peroneal tendon pathologies in patients undergoing arthroscopic repair for lateral ankle instability.

Methods: Patients were stratified into those who underwent arthroscopic ankle lateral ligament repair alone (Group N) and those who underwent arthroscopic ankle lateral ligament repair in combination with surgery for peroneal tendon pathologies (Group P). Group P was further divided into patients without peroneal tendon dislocation (Group PT) and those with peroneal tendon dislocation (Group PD). Arthroscopic ankle lateral ligament repair was performed first, followed by additional surgery for peroneal tendon pathology in Group P. Subjective clinical outcome scores were assessed preoperatively and at 2 years postoperatively using the Self-Administered Foot Evaluation Questionnaire (SAFE-Q).

Results: A total of 311 patients who met the inclusion and exclusion criteria were included in this study. There were 248 patients in Group N and 63 patients in Group P. Of the 63 patients in Group P, 46 were classified into Group PT and 17 into Group PD. In all groups, SAFE-Q scores significantly improved in all categories 2 years after surgery compared with preoperatively. At 2 years postoperatively, SAFE-Q scores showed statistically significant differences in all categories between Group P and Group N, Group PT and Group N, and Group PD and Group N (p < 0.0001), with Group N having higher scores.

Conclusions: Although surgical treatment for lateral ankle instability associated with peroneal tendon pathologies was effective, the presence of peroneal tendon pathologies had a negative effect on the postoperative clinical outcomes of arthroscopic repair for lateral ankle instability.

Figure 5

Peroneal brevis tendon tear (left) and after debridement (right).

The peroneal brevis tendon tears (*) and/or degenerated tendon were treated with debridement and tubularization while preserving the reasonable native tendon (†).

*: Dislocated peroneal brevis tendon passing over the posterior edge of the LM.

LM: lateral malleolus.

Introduction

Chronic lateral ankle instability has been reported to be associated with various pathologies, including osteochondral lesions of the talus, soft tissue impingement lesions, osseous loose bodies, peroneal tendon disorders, and other associated injuries that may contribute to postoperative pain.^1-9 Among these, peroneal tendon pathologies are common and are reportedly associated with lateral ankle instability in 8.7%-77% of cases, with 53.3% requiring surgical intervention.^1,10-13 Furthermore, peroneal pathology is a known risk factor for failure of conservative treatment and persistent ankle symptoms following lateral ligament reconstruction.^14-16

Lateral ligament repair of the ankle is indicated when non operative measures have failed to alleviate pain, improve function, and prevent subsequent injuries such as osteochondral lesions of the talar dome. Moreover, ankle stabilization may also improve sports performance by improving the biomechanics of the ankle.¹⁷ The direct anatomic repair of the lateral ligaments of the ankle was originally described by Broström in 1966¹⁸ and has since evolved into a minimally invasive arthroscopic procedure.^19-27 Arthroscopic ankle lateral ligament repair allows direct visualization for ligament repair, thereby minimizing damage to nerves and vessels while ensuring a quicker return to athletic activities. However, there have been few reports on the effects of surgical treatment for peroneal tendon pathologies on clinical outcomes when performing arthroscopic repair for lateral ankle instability.

This study hypothesized that peroneal tendon pathologies negatively impact the clinical outcomes of arthroscopic ligament repair for lateral ankle instability. The purpose of this investigation was to identify the effects of peroneal tendon pathologies in patients who underwent arthroscopic repair for lateral ankle instability.

Materials and Methods

All patients provided written informed consent to participate in this study, and ethical approval for this research was obtained from a relevant institutional review board, with all procedures complying with applicable ethical standards.

The diagnosis of lateral ankle instability was established through clinical history, a positive anterior drawer sign, and discontinuity and/or waviness of the anterior talofibular ligament on ultrasonography (US), which is recognized for its sensitivity and specificity.²⁸ Following the failure of non-operative treatments, patients were offered arthroscopic ankle lateral ligament repair with a modified lasso-loop technique, contingent upon the absence of os subfibulare and the satisfactory quality of the residual ligament as determined by stress US.²⁹

The diagnoses of peroneal tendon pathologies were established through clinical history, which included peroneal swelling, pain, and tenderness. Magnetic resonance imaging (MRI) and US were performed in patients with abnormal clinical findings.^30,31 Positive MRI findings for peroneal tendon pathologies included peroneal tendon edema, thickening, a flattened or C-shaped tendon, irregularity of the surrounding tissues, and excessive fluid within the tendon sheath (Figure 1).³¹ Positive US findings for peroneal tendon pathologies included peroneal tendon swelling, defects, thickening, and peritendinous irregularity (Figure 2).³² Peroneal tendon dislocation was diagnosed by tenderness and manual confirmation that the peroneal tendon had dislocated from the peroneal groove (Figure 3).³³

Figure 1

Transverse plane of T2-weighted magnetic resonance imaging.

*: Thickened peroneal brevis tendon, †: irregularity of the surrounding soft tissues, arrow: excessive fluid within the tendon sheath.

Figure 2

Short axis view of ultrasonography.

*: Thickened peroneal brevis tendon, †: irregularity of the surrounding soft tissues.

Figure 3

Manually dislocated peroneal tendon.

*: Dislocated peroneal tendon passing over the posterior edge of the LM.

LM: lateral malleolus.

Between April 2017 and March 2023, 1264 ankles in 878 patients underwent arthroscopic repair of the ankle lateral ligament. The inclusion criterion was a minimum of 2 years of postoperative follow-up. The exclusion criteria were as follows: simultaneous bilateral surgery; skeletal immaturity; open surgery or reconstruction using grafts for lateral ankle instability; history of ankle surgery; and associated ankle lesions other than peroneal pathology, including osteochondral lesions, anterior and posterior ankle impingement, deltoid ligament tears, tibiofibular ligament tears, accessory navicular, and Achilles tendon pathologies. Among patients who met the inclusion and exclusion criteria, Group N consisted of those who underwent arthroscopic ankle lateral ligament repair alone without surgery for the peroneal tendon, and Group P consisted of those who underwent arthroscopic ankle lateral ligament repair in combination with surgery for peroneal tendon pathologies. Group P was further subdivided into Group PT, which did not involve peroneal tendon dislocation, and Group PD, which involved peroneal tendon dislocation.

Surgical Procedure

First, arthroscopic ankle lateral ligament repair was performed. The patients were placed in a supine position with a lower leg holder. A tourniquet was applied to the thigh if bleeding obstructed the field of vision. A medial midline portal was used as the viewing portal, and an accessory anterolateral portal was used as the working portal. After confirming that the remaining ligament fibers of the anterior talofibular ligament were adequate for repair, a suture anchor was inserted by drilling a pilot hole at the distal end of the anterior inferior tibiofibular ligament approximately 5 mm outward from the lateral edge of the articular surface. The remaining ligament was then reattached to the anatomical fibular attachment using the modified lasso-loop technique.³²

Patients with positive findings on either MRI or US and/or peroneal tendon dislocations underwent open surgery for peroneal tendon pathologies following arthroscopic ankle lateral ligament repair. A curved skin incision approximately 4 cm long was made along the posterior edge of the lateral malleolus, extending 1 cm distal to the fibular tip. The peroneal retinaculum was subsequently detached from the fibula, and the peroneal tendon was exposed. Any hypertrophic synovium and/or low-lying peroneal brevis muscle belly was excised (Figure 4). Peroneal tendon tears and/or degenerated tendons (Figure 5, left) were treated with debridement and tubularization while preserving the reasonable native tendon, regardless of the size of the lesions (Figure 5, right).³⁴ Repair of the detached peroneal tendon retinaculum and treatment of peroneal tendon dislocation were performed with superficial peroneal retinaculum repair using two suture anchors after tendon reduction (Figure 6).³⁵

Figure 4

Low-lying peroneal brevis muscle (*)

Figure 5

Peroneal brevis tendon tear (left) and after debridement (right).

The peroneal brevis tendon tears (*) and/or degenerated tendon were treated with debridement and tubularization while preserving the reasonable native tendon (†).

*: Dislocated peroneal brevis tendon passing over the posterior edge of the LM.

LM: lateral malleolus.

Figure 6

Superficial peroneal retinaculum repair.

*: Repaired superficial peroneal retinaculum.

Postoperative Management

For Group P, ambulation was allowed based on pain levels starting the day after surgery, using a patellar tendon bearing (PTB) brace for 3 weeks. Weight-bearing activities without the PTB brace were allowed at 3 weeks postoperatively. Jogging and proprioceptive training were permitted from 4 to 6 weeks postoperatively and return to sports was allowed 8 to 12 weeks postoperatively.

For Group N, an elastic bandage was applied for 2 days. Full weight bearing was allowed based on pain levels starting from day 1 after surgery. Jogging and proprioceptive training were permitted at 2 weeks postoperatively and return to sports without external fixation was allowed at 6 weeks postoperatively.

Evaluations

Subjective clinical outcome scores were assessed preoperatively and 2 years after surgery using the Self-Administered Foot Evaluation Questionnaire (SAFE-Q).^36,37 The main body of the SAFE-Q consists of 34 questionnaire items, with five subscale scores (1: Pain and Pain-Related; 2: Physical Functioning and Daily Living; 3: Social Functioning; 4: Shoe-Related; 5: General Health and Well-Being). Each subscale was converted to a 100-point scale. The test-retest reliability of the SAFE-Q has been previously verified.³⁶ The results were compared between Group P and N, Group PT and N, Group PD and N, and Group PT and PD.

Statistical Analysis

Student’s t-test or chi-square test was used to analyze differences in patient characteristics and SAFE-Q scores between the two groups (Group P and Group N, Group PT and Group N, Group PD and Group N, and Group PT and Group PD) at two different time points (pre-operation and 2 years postoperatively). All data are presented as means ± standard deviations. A p < 0.05 was considered to indicate statistical significance. The results are shown as mean ± standard error of the mean. JMP 14.3 statistical software (SAS Institute Inc., Cary, NC, USA) was used to perform the statistical analyses. During the planning of this study, we performed a power analysis using G*Power 3.1.9.7 for Windows (Heinrich Heine University, Düsseldorf, Germany). Because no previous similar study exist, we assumed an effect size using Cohen’s power table (power primer). With an effect size “w” of 0.4 (medium size), a total of 124 samples provided 80% power at a two-tailed α of 0.05.

Results

A total of 311 patients who met the inclusion and exclusion criteria were included in this study. There were 63 patients (20.3%) in Group P (21 males and 42 females; mean age, 30.6 ± 18.1 years) with 46 patients in Group PT (18 males and 28 females; mean age, 30.2 ± 18.0 years) and 17 patients in Group PD (3 males and 14 females; mean age, 31.6 ± 19.0 years). Group N included 248 patients (99 males and 149 females; mean age, 28.2 ± 15.5 years). There were no statistically significant differences in age among the groups (Group P versus N, p = 0.2912; Group PT versus N, p = 0.4359; Group PD versus N, p = 0.3780; Group PT versus PD, p = 0.7736).

In all groups, SAFE-Q scores significantly improved in all categories two years after surgery compared with preoperatively (Tables 1-4). Preoperative SAFE-Q scores were not significantly different between Group P and Group N, Group PT and Group N, Group PD and Group N, or Group PT and Group PD in any category except for the shoe-related category in Group P versus Group N (p = 0.0298) and Group PT versus Group N (p = 0.0466) (Table 5). At 2 years after surgery, SAFE-Q scores showed statistically significant differences in all categories between Group P and Group N, Group PT and Group N, and Group PD and Group N (p < 0.0001), with Group N scoring higher in each case (Table 5)

Table 1

Mean SAFE-Q Scores in Group P (Range).

Table 2

Mean SAFE-Q Scores in Group PT (Range).

Table 3

Mean SAFE-Q Scores in Group PD (Range).

Table 4

Mean SAFE-Q Scores in Group N (Range).

Table 5

p-Values for SAFE-Q Scores among Groups before Surgery and at 2 Years after Surgery.

In Group P, two patients (3.2%) developed transient peroneal tenosynovitis, and one patient (1.6%) developed transient sural neuropathy after surgery; all symptoms resolved within 4 weeks. Recurrent instability due to reinjury from ankle sprain occurred in eight cases overall (2.6%), including six cases in Group N (2.4%) and two cases in Group P (3.2%).

Discussion

The most important finding in this study was that, when comparing the objective clinical evaluation criteria (SAFE-Q) of Group N, which underwent arthroscopic repair of the ankle lateral ligament, and Group P, which underwent simultaneous surgery for peroneal pathology, there was no statistically significant difference preoperatively except in the shoe-related category. In Group P, all SAFE-Q categories significantly improved 2 years after surgery compared with preoperatively, demonstrating that surgical treatment for lateral instability associated with peroneal tendon pathologies was effective. However, 2 years after surgery, Group P had significantly lower scores than Group N in all SAFE-Q categories. This finding indicates that peroneal tendon pathologies had a negative effect on postoperative clinical outcomes following arthroscopic repair of lateral ankle instability.

On the lateral side of the ankle, the lateral ligaments act as static stabilizers, and the peroneal tendons act as dynamic stabilizers. In chronic ankle instability, the prevailing theory based on human and cadaveric studies is that the lateral ankle ligaments fail, and the peroneal tendons serve as an important secondary dynamic stabilizer.^38-41 However, the function of the peroneal tendon alone is insufficient to provide adequate stability, and repeated episodes of lateral ankle instability can gradually weaken the peroneal retinaculum, causing the tendon to subluxate and rupture at the sharp edge of the posterolateral fibular tip.^14,42 Furthermore, it has been reported that ankle instability can lead to deactivation or weakness of the peroneal muscles, which in turn leads to further ankle instability and progressive weakening of the peroneal retinaculum.^43-45 In vivo three-dimensional gait analysis has revealed significant changes in hindfoot motion, ankle motion, and ankle power, and has demonstrated a strong association between peroneal tendon tears and diminished ankle plantarflexion strength.⁴⁶ Therefore, ankle instability should be treated before peroneal tendon pathologies develop, and treatment is required for peroneal tendon pathologies simultaneously in cases where they are associated with lateral ankle instability.

For surgical debridement of torn and/or degenerated peroneal tendons, some authors suggest that tendon transfer, tenodesis, or allograft replacement becomes necessary if more than 50% of the tendon must be removed.⁴⁷ However, the evidence supporting these recommendations is limited and remains a subject of debate.^30,48 The recent European Society of Sports Traumatology, Knee Surgery and Arthroscopy-Ankle and Foot Associates Section (ESSKA-AFAS) international consensus statement concluded that it is generally preferable to attempt to preserve the tendon tissue with primary debridement and tubularization when at least some reasonable native tendon can be preserved in the repair, even if more than 50%.⁴⁸ In this study, debridement and tubularization were also performed according to the ESSKA-AFAS consensus.

Previous reports have shown that peroneal tendon lesions are associated with lateral ankle instability in 8.7%-77% of cases,^1,10-13 but in this study, the incidence in Group P was 63 of 311 cases (20.3%), which is relatively low compared to those reports. In previous reports, open surgery was performed for lateral ankle instability and peroneal tendon pathologies were diagnosed under direct vision. However, in this study, arthroscopic surgery was performed for lateral ankle instability, and the diagnosis of peroneal tendon pathologies was made using preoperative MRI and US. MRI has a sensitivity of 83%-90% and a specificity of 72%-75%.^31,49 The accuracy of US remains highly dependent on the operator and the machine.³¹ This suggests that there may have been false-negative cases that were not detected by preoperative MRI and US. Improving the accuracy of preoperative imaging for peroneal pathologies is expected to lead to better treatment outcomes for lateral ankle instability associated with peroneal pathologies. Another limitation of this study is that the sample sizes of the subgroups were relatively small, and Groups P and N underwent different rehabilitation protocols. While this is clinically relevant, it may have complicated the comparative analysis of the results.

Conclusions

The effects of peroneal tendon pathologies on the objective clinical evaluation criterion (SAFE-Q) in arthroscopic repair of the ankle lateral ligament were investigated. In Group P, which had peroneal tendon pathologies, all SAFE-Q categories improved significantly 2 years after surgery compared with preoperative scores, indicating that surgical treatment for lateral ankle instability associated with peroneal tendon pathologies was effective. However, Group P had significantly lower scores than those of Group N across all SAFE-Q categories, suggesting that peroneal tendon pathologies had a negative effect on the postoperative clinical outcomes of arthroscopic repair of lateral ankle instability. Therefore, because ankle instability lead to deterioration of the peroneal tendon over time, it is necessary to improve ankle instability before peroneal tendon injury occurs.

Author Contributions

Yasuyuki Jujo was responsible for the overall study concept and the manuscript writing. Taihei Miura collected the experimental data and performed the analysis. Masato Takao provided oversight and critical revisions. All authors contributed to the final manuscript and approved it for submission.

Conflicts of interest

The authors declare that there are no conflicts of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors

Ethical Approval and Informed Consent

All patients provided written informed consent to participate in this study, which was approved by the Ethics Committee of the Japan Medical Association (approval number: R1-6).

Disclaimer

Masato Takao is one of the Associate Editors of Journal of Orthopaedic Foot and Ankle Science and on the journal’s Editorial Board. This author was not involved in the editorial evaluation or decision to accept this article for publication at all.

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