Return to Sport after Surgical Treatment for Dislocation of the Peroneal Tendon: A Systematic Review of the Current Literature

Abstract

Purpose: This study aims to analyze the return to normal activities and sports after surgical management of peroneal tendon dislocation through different surgical techniques. Methods: This review included studies (retrospective case series, prospective cohort study) that analyzed different aspects: return to sport (RTS), American Orthopedic Foot and Ankle Society Score (AOFAS), Visual Analogue Scale (VAS), satisfaction, and redislocation episodes after surgical treatment. We performed a systematic review, analyzing 1699 articles. We researched our selected studies through PubMed, Scopus, and Cochrane. The last search was performed in December 2022. We used the MINORS score to perform a quality assessment of pooled data. In total, 20 studies were included. Results: The postoperative AOFAS score, VAS scale, and high satisfaction percentages all improve with surgical therapy. At long-term follow-up, the redislocation following surgical treatment is minimal. Compared to patients who only receive superior peroneal retinaculum (SPR) repair and other surgical procedures, patients with groove deepening and SPR repair have greater rates of returning to sports (bony and rerouting procedures). Conclusions: Peroneal tendon dislocation surgery offers good outcomes, a quick return to sport, and high patient satisfaction. Those who received both groove deepening and SPR repair as opposed to other surgical procedures have greater rates of returning to sports.

1. Introduction

The rapid dorsiflexion of the forced inverted foot can cause, through an acute contraction mechanism of the peroneal muscles, the laceration of the superior peroneal retinaculum (SPR). Once the SPR is injured, the tendons may suffer subluxations or dislocations [1,2]. This traumatic injury occurs most often in athletic patients who participate in impact sports, particularly skiers [3,4]. Peroneal tendon dislocation is a rare event that is often overlooked, occurring in 0.3–0.5% of all ankle injuries [5]. Failure to diagnose and improper treatment result in chronic lateral ankle pain that affects daily life and sports performance. In chronic cases, because of the importance of the peroneal tendons in the mechanisms of foot eversion and step phases, patients may have difficulty releasing the foot during walking.

There are several associated conditions, including lateral ligamentous instability, cavo-varus hindfoot alignment, enlarged peroneal tubercle, accessory peroneus quarto or quintus, concavity or flat retromalleolar groove, os peroneus, calcaneal malunion, and sub-fibular impingement [6,7,8,9,10,11,12,13,14,15].

Usually, the patient describes a popping sensation and lateral instability in acute pain; eversion movements and plantarflexion exacerbate the painful symptomatology. In some cases, the patient can voluntarily dislocate the tendons, which may or may not be associated with the popping sound [16].

Conservative treatment with cast immobilization for six weeks without weight-bearing may be indicated in nonprofessional athletes with a failure rate for peroneal instability of nearly 50% [17,18]. Several surgical procedures for the treatment of dislocations of the peroneal tendons are described. Some of these treatments are aimed at correcting the previously mentioned anatomic conditions associated with this condition.

The most commonly used technique in patients with high functional demands is the repair of the superior peroneal retinaculum and deepening of the retromalleolar groove. Good results are described in the literature with a rapid return to sports activity, especially in patients undergoing both procedures [19]. This study aims to review the current literature and evaluate which surgical approach improves outcomes and allows for a better return to sports activity.

2. Materials and Methods

This research review was carried out utilizing the PRISMA checklist and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) criteria [20]. (Figure 1). This publication contains clinical trials that assessed patients’ ability to resume their regular daily activities and their participation in sports following peroneal tendon dislocation surgery.

2.1. Study Selection

Two authors performed the literature search and independently reviewed the search results (P.D.S., S.B.). The following string was used: (“peroneal” [All Fields] OR “peroneals” [All Fields] OR “peroneous” [All Fields]) AND (“dislocate” [All Fields] OR “dislocated” [All Fields] OR “dislocates” [All Fields] OR “dislocating” [All Fields] OR “dislocator” [All Fields] OR “dislocators” [All Fields] OR “joint dislocations” [MeSH Terms] OR (“joint” [All Fields] AND “dislocations” [All Fields]) OR “joint dislocations” [All Fields] OR “dislocation” [All Fields] OR “dislocations” [All Fields]).

2.2. Data Collection, Analysis, and Outcome

Two authors performed data extraction (P.D.S. and S.B.). The following data were extracted from the included studies: Study design, level of evidence (LOE), type of intervention, patients’ demographics (number of patients, age, gender, BMI), concomitant ankle comorbidities, follow-up.

2.3. Clinical Outcome Evaluation

This review evaluated the rate and time to return to sport (RTS), the improvement of the AOFAS score and VAS scale, satisfaction, and the risk of redislocation after the different surgical treatments.

In particular; the AOFAS score (American Orthopedic Foot and Ankle Society Score) analyzes pain, function (limitations in daily-life activities and need for aids; the maximum distance it can travel, in hundreds of meters; Walkable areas; gait abnormalities; Sagittal movement (flexion + extension); Rearfoot movement (inversion and eversion); Ankle and rearfoot stability (anteroposterior, varus, valgus); Alignment [21]. The VAS scale allows estimation of pain intensity with a score from 1 to 10 [22].

2.4. Inclusion Criteria

The inclusion criteria included English language studies that analyzed the return to normal activities and resumption of sports activities after undergoing surgical procedures for repair of the superior peroneal retinaculum and/or deepening of the retromalleolar groove. Original studies that assessed AOFAS and VAS scores, return to sports activity, mean recovery time, patient satisfaction, and redislocation were included.

Exclusion criteria were studies that involved patients with additional trauma and injuries who had undergone additional surgical procedures, those that did not consider returning to sports activity, and those that considered other surgical procedures.

In addition, case reports, imaging reviews, and surgical technique reports were excluded.

2.5. Risk of Bias Assessment

Two reviewers (P.D.S. and S.B.) used the Methodological Index for Non-Randomized Studies (MINORS) score to evaluate the methodological quality of non-randomized studies, whether comparative or non-comparative.

3. Results

This brought us to identify a total of 1699 different records: 617 studies from PubMed, 44 studies from Cochrane, and 602 studies from Scopus.

Duplicate records were removed (n = 127); in addition, several papers were removed for irrelevance to the purpose of the study (n = 85).

After the first screening, we got 1051 records; the following review based on the studies sought for retrieval gave us 75 remaining studies.

The eligibility criteria (Return to sport) were applied to the titles and abstracts, and possibly pertinent articles were assessed in full text. The reports assessed for eligibility were 67. The reports excluded were: not reporting selected outcomes (n = 19), protocol of RTC (n = 8), not presenting adequate comparison (n = 16), and level IV or V of evidence (n = 4). At last, we reached a few of the 20 studies that were included in our review.

3.1. Evaluation of Study Characteristics

Seventeen retrospective case series, two case series, and one prospective cohort study were selected for a total of 397 patients. The average patient was 27.7 years old. A 36-month follow-up was average.

Table 1. Baseline characteristics. RCS, retrospective case series; CS, case series; PCS, prospective cohort study; RC + RoL, retrospective case series + review of literature; RCCS, retrospective, comparative case series; y, years; M, male; F, female; n.r., not reported; m, months.

Study (Year)	Study Design	LOE	Type of Intervention	Baseline Carachteristics				Concomitant Ankle Comorbidities	Follow-Up
Kollias et al. 1997 [23]	RCS	IV	Groove deepening and SPR repair	n	age	gender	BMI	Intra articular changes (N = 10) Lateral ankle instability (N = 3)	6 y
				11	25 y	Unknown	\
Hui et al. 1998 [24]	RCS	IV	SPR repair	21	24 y	86% M–14% F	Not found	n.r.	9.3 y
Porter et al. 2005 [25]	CS	IV	Groove deepening and SPR repair	13	24 y	69% M–31% F	\	0	>1 y
Adachi et al. 2006 [26]	RCS	IV	SPR repair	20	24 y	85% M–15% F	\	Lateral ankle instability (N = 2)	3.16 y
Maffulli et al. 2006 [1]	RCS	IV	SPR repair	14	25 y	100% M	\	n.r.	3.16 y
Karlsson et al. 2007 [27]	RCS	IV	Groove deepening and SPR repair	15	23 y	67% M–33% F	\	n.r.	3.5 y
Ogawa et al. 2007 [28]	RCS	IV	Groove deepening and SPR repair	15	33 y	53% M–47% F	\	0	1.08 y
Raikin et al. 2008 [29]	RCS	IV	Groove deepening and SPR repair	14	34 y	100% M	\	Peroneal brevis rupture (N = 5) Peroneal longus rupture (N = 1)	2.67 y
Walther et al. 2008 [16]	CS	IV	Groove deepening and SPR repair	23	34 y	Unknown	\	0	2 y
Wang et al. 2009 [30]	RCS	IV	Rerouting procedure	17	23 y	100% M	\	0	2.34 y
Saxena et al. 2010 [31]	PCS	II	Groove deepening and SPR repair	31	33 y	Unknown	\	Peroneal brevis rupture (N = 9) Ankle instability (N = 6)	>2 y
Tomihara et al. 2010 [32]	PCS-CCS	IV	SPR repair	P	23 y	79% M–21% F	\	n.r.	4.25 y
Tomihara et al. 2010 [32]	PCS-CCS		Bony procedure	15	17 y	67% M–33% F	\	n.r.	5.5 y
Zhenbo et al. 2014 [33]	PCS-CCS	III	Bony procedure	26	29 y	69% M–31% F	\	0	4.75 y
Cho et al. 2014 [34]	PCS-CCS (group B)	II	SPR repair	29	21 y	100% M	23.6	0	2.75 y
	PCS-CCS (group A)		Groove deepening and SPR repair	29	21 y	100% M	23.8	0	2.08 y
Saragas et al. 2015 [35]	RCS + RoL	IV	SPR repair	16	20–50 y	74% M–26% F	\	n.r.	4.42 y
			Groove deepening and SPR repair	7
Suh et al. 2017 [36]	RCS	IV	Groove deepening using low-profile snap-off screws	34	35 ± 15 y	65% M–35% F	\	16 Peroneal tendon tear lateral ankle instability subtalar arthritis	4 y
Hu et al. 2018 [37]	RCS	IV	Groove deepening and SPR repair	21	29 y	71% M–29% F	\	Not reported	4 y
Park SH et al. 2021 [38]	RCS	IV	SPR repair	36	14–56 y	75% M–25% F	22.4	\	2 y

shows the baseline characteristics.

Five groups of treatment possibilities were distinguished: GROUP A: SPR repair; GROUP B: groove deepening and SPR Repair; GROUP C: bone procedures (the procedure consists of a partial fibular osteotomy creating a “graft” which is slided posteriorly and then fixed with absorbable screws); GROUP D: Rerouting method; and GROUP A+: groove deepening using low-profile snap-off screws (

Table 2. Type of surgery.

Type of Surgery
Group A	Group A+	Group B	Group C	Group D
SPR repair	Groove deepening using low-profile snap-off screws	Groove deepening and SPR repair	Bone procedure	Rerouting procedure

). Results are presented in

Table 3. Outcomes. n.r., not reported; m, months; E, excellent; G, good; P, poor; F, fair.

Study (Year)	Rate of Return to Sports	Mean Return to Sports	AOFAS		VAS		Satisfaction	Redislocation
Kollias et al. 1997 [23]	91%	9.1 m	Pre	Post	Pre	Post
			53	96	n.r.	n.r.	/	0
Hui et al. 1998 [24]	86%	/	/	/	/	/	/	0
Porter et al. 2005 [25]	100%	3.0 m	/	/	n.r.	n.r.	/	0
Adachi et al. 2006 [26]	83%	/	76	93	n.r.	n.r.	/	0
Maffulli et al. 2006 [1]	/	/	54.3 ± 11	94.5 ± 6.4	n.r.	n.r.	E = 12, G = 2	0
Karlsson et al. 2007 [27]	100%	4.5 m	/	/	n.r.	n.r.	/	0
Ogawa et al. 2007 [28]	/	/	/	/	n.r.	n.r.	/	0
Raikin et al. 2008 [29]	/	/	61	93	6.8	1.2	E = 9, G = 4, F = 1	1
Walther et al. 2008 [16]	100%	/	69	95	n.r.	n.r.	/	0
Wang et al. 2009 [30]	100%	2.8 m	73	100	n.r.	n.r.	E = 17	0
Saxena et al. 2010 [31]	100%	3.2 m	58	97	n.r.	n.r.	/	1
Tomihara et al. 2010 [32]	80%	2.9 m	78	93	GROUP A		/	0
					n.r.
	54.40%	3.9 m	77	89	GROUP B		/	2
					n.r.
Zhenbo et al. 2014 [33]	88%	4.4 m	56	88	7.4	1.4	E = 12, G = 11, F = 3	0
Cho et al. 2014 [34]	100%	3.0 m	60	93	GROUP A		E = 4, G = 10, p = 2	1
					5	1
	100%	3.1 m	59	91	GROUP B		E = 3, G = 9, p = 1	0
					4.9	1.2
Saragas et al. 2015 [35]	100%	/	/	85	n.r.	1.5	16 excellent	/
							1 good
							1 uncertain
							2 poor
Suh et al. 2017 [36]	no concomitant patologies	/	69.96 ± 13.14	87.72 ± 10.13	n.r.	n.r.	17 excellent	0
	52.9%	2.95 ± 0.19 m
	versus	/					12 good
	concomitant patologies	/
	47.1%	4.14 ± 1.34 m					5 fair
Hu et al. 2018 [37]	100%	/	55	93.6	5.3	1.2	Not well	0
							reported
							(excellent
							results)
Park SH et al. 2021 [38]	100%	8 m	77.2	94.3	3.4	0.6	15 excellent	2
							1 good

.

3.2. Rate of Return to Sports

Data from 397 patients related to their return to sport was obtained. After surgical correction of the peroneal tendon dislocation, the RTS rate ranged from 47.1% to 100%. Studies that enrolled patients (179) treated with SPR repair + groove deepening (Group B) showed a 99.4% (178) RTS. It ranged from 91% to 100%. Studies that enrolled patients (155) treated with SPR Repair alone (Group A) showed a 93.5% (145) RTS. It ranged from 80% to 100%. Studies that enrolled patients (34) treated with groove deepening using low-profile snap-off screws (Group A+) showed a 100% (34) RTS. There are no ranges because we found only one study that analyzed this type of procedure. Studies that enrolled patients (41) treated with bone procedures (Group C) showed a 75.6% (31) RTS. It ranged from 54.4% to 88%. Studies that enrolled patients (17) treated with Rerouting procedures (Group D) showed a 100% (34) RTS. There are no ranges because we found only one study that analyzed this type of procedure: 91% to 100% in GROUP B, 54.4% to 88% in GROUP C, and 100% in GROUP D. The group that reported the highest improvement in the AOFAS score is GROUP B. The group that reported the worst improvement in the AOFAS score is GROUP A+ [36]—preoperative AOFAS: 69.96 ± 13.14 (45 to 88); postoperative AOFAS: 87.72 ± 10.13 (58 to 100).

3.3. Time to Return to Sport

Time to RTS was analyzed in 10 studies. These studies showed a mean of 51.2 months to return to sport in 246 patients evaluated.

Studies that analyzed the time to return to sport in patients who received SPR repair + groove deepening (Group B—98 patients) showed a mean of 4.4 months.

Studies that analyzed the time to return to sport in patients who received SPR repair alone (Group A—80 patients) showed a mean of 4.6 months.

Studies that analyzed the time to return to sport in patients who received SPR repair (Group A+—34 patients) showed a mean of 3.5 months.

In GROUP A+, 52.9% of patients (patients treated with groove deepening using low-profile snap-off screws) without coexisting pathologies returned to sport 2.95 months after surgical treatment, compared to 47.1% of patients with coexisting pathologies who returned to sport at least 4 months after surgical treatment.

Studies that analyzed the time to return to sport in patients who received Bony procedures (Group C—31 patients) showed a mean of 4.2 months.

Studies that analyzed the time to return to sport in patients who received Rerouting procedures (Group D—17 patients) showed a mean of 2.8 months.

3.4. AOFAS Score

The AOFAS score (American Orthopedic Foot and Ankle Society Score) analyzes pain, function (limitations in daily-life activities and need for aids); maximum distance it can travel, in hundreds of meters; walkable areas; gait abnormalities; sagittal movement (flexion + extension); rearfoot movement (inversion + eversion); ankle and rearfoot stability (anteroposterior, varus, and valgus); and alignment [21]. These items were assessed in 16 studies. The range of the mean preoperative AOFAS score was 53 to 78, and the range of the mean postoperative AOFAS score was 85 to 100 among all the studies reviewed. The AOFAS score significantly improved following surgery in every study that was examined.

Between groups, we can assess that:

-

Group B patients improved their AOFAS score from 51.5 to 94.3 (129 patients).

-

Group A patients improved their AOFAS score from 69 to 94 (118 patients).

-

Group A+ patients improved their AOFAS score from 70 to 88 (34 patients).

-

Group C patients improved their AOFAS score from 67 to 89 (41 patients).

-

Group D patients improved their AOFAS score from 73 to 100 (17 patients).

The group analyzed in Saragas shows only a post-operative AOFAS score of 85 without analyzing the pre-operative one [35].

3.5. VAS Scale

Ankle pain was assessed by the VAS (Visual Analogue Scale) in six studies [29,33,34,35,37,38] The mean VAS scale score before surgery ranged from 3.4 to 7.4, and the mean VAS scale score ranged from 0.6 to 1.5 after surgery. After surgical intervention, the VAS scale significantly improved across all the studies evaluated.

Between groups, we can assess that:

-

Group B patients improved their VAS scale from 5.7 to 1.2 (64 patients).

-

Group A patients improved their VAS scale from 4.2 to 0.8 (65 patients).

-

The Group A+ VAS scale was not analyzed.

-

Group C patients improved their VAS scale from 7.4 to 1.4 (26 patients).

-

In Group D, the VAS scale was not analyzed.

3.6. Satisfaction

The patients’ satisfaction was analyzed in 10 studies. The results were excellent, good, uncertain, or fair. 105 patients stated their satisfaction as excellent after surgical treatment; 50 patients stated their satisfaction as good after surgical treatment; 1 patient stated their satisfaction as uncertain after surgical treatment; and 14 patients stated their satisfaction as fair or poor after surgical treatment.

This shows a high level of satisfaction among patients who have undergone these types of treatments.

Between groups, we can assess that:

-

Among the studies in Group B, 4 analyzed patients’ satisfaction after surgical treatment: 37 patients described their satisfaction as Excellent (E) (63%), 16 patients described their satisfaction as Good (G), 5 patients described their satisfaction as Fair (F) or Poor (P), and 1 was uncertain.

-

Among the studies in Group A, 4 analyzed patients’ satisfaction after surgical treatment: 47 patients described their satisfaction as Excellent (E) (49.5%), 14 patients described their satisfaction as Good (G), 4 patients described their satisfaction as Fair (F) or Poor (P), and 1 was uncertain.

-

Among the studies in Group C, 2 analyzed patients’ satisfaction after surgical treatment: 12 patients described their satisfaction as Excellent (E) (46%), 11 patients described their satisfaction as Good (G), and 3 patients described their satisfaction as Fair (F) or Poor (P).

-

Among Group A+, 1 study analyzed patients’ satisfaction after surgical treatment: 17 patients described their satisfaction as Excellent (E) (50%), 12 patients described their satisfaction as Good (G), and 5 patients described their satisfaction as Fair (F) or Poor (P).

-

Among Group D, 1 study analyzed patients’ satisfaction after surgical treatment: 17 patients described their satisfaction as Excellent (E) (100%).

3.7. Redislocation

Cases of redislocation were found in five out of twenty studies. Park SH et al. 2021 [38] found two cases of redislocation: one case occurred 6 months after surgery during sports activities, and one case occurred 20 months after surgery during fast running.

Cho et al. [34] found one case of redislocation: one of sixteen patients treated by SPR alone experienced subluxation but not complete dislocation at 2 months postoperatively. The malleolar groove of this patient was concave, not shallow. In the reoperation, the retinaculum was not robust enough to withstand repair, and the suturing of the retinaculum was also loose. Therefore, the retinaculum was sutured tightly. Three months after the second operation, the patient resumed sports activities, and a 24-month follow-up revealed no subluxation or dislocation.

In one patient with type-B subluxation, recurring intrasheath subluxation could be reproduced with vigorous ankle eversion and dorsiflexion, according to Raikin et al. [29] According to Saxena et al. [31], in one case of redislocation, the patient needed additional surgery that included debulking of the peroneus brevis muscle.

Tomihara et al. [32] reported two cases of redislocation that were not better described. We can assess that among Group B patients, nine studies analyzed cases of redislocation, and only one case out of 208 treated patients. Among Group A patients, six studies analyzed cases of redislocation. They reported three cases out of 139 treated patients. Among Group A+ patients, one study analyzed cases of redislocation. It reported no cases out of thirty-four treated patients. Among Group C patients, two studies analyzed cases of redislocation. They reported two cases out of forty-one treated patients. Among Group D patients, one study analyzed cases of redislocation. It reported no cases out of 17 treated patients.

4. Quality Assessment

For each of the listed studies, we determined the MINORS score (

Table 4. Minors.

Study	Stated Aim	Inclusion of Patients	Data Collection	Endpoints Appropriate to the Aim	Unbiased Assessment of the Study Endpoint	Follow-up (6 m)	Loss to Follow Up Less than 5%	Prospective Calculation of the Study Size	Control Group	Contemporary Groups	Baseline Equivalence of Groups	statistical Analyses	Total
Adachi et al. [26]	2	2	2	2	1	2	0	/	/	/	/	/	11
Cho et al. [34]	2	2	1	2	1	2	0	1	2	2	2	2	19
Hui et al. [24]	2	2	2	2	1	\	0	/	/	/	/	/	9
Karlsson et al. [27]	2	2	2	2	1	2	0	/	/	/	/	/	11
Kollias et al. [23]	2	2	2	2	1	2	0	/	/	/	/	/	11
Maffulli et al. [1]	2	2	2	2	1	2	0	/	/	/	/	/	11
Ogawa et al. [28]	2	2	2	2	1	2	0	/	/	/	/	/	11
Porter et al. [25]	2	2	2	2	1	2	0	/	/	/	/	/	11
Raikin et al. [29]	2	2	2	2	1	2	0	/	/	/	/	/	11
Saxena et al. [31]	2	2	1	2	1	2	0	/	/	/	/	/	10
Tomihara et al. [32]	2	2	2	2	1	2	0	1	2	2	2	2	20
Walther et al. [13,16]	2	2	2	2	1	2	0	/	/	/	/	/	11
Wang et al. [30]	2	2	2	2	1	2	0	/	/	/	/	/	11
Zhenbo et al. [33]	2	2	2	2	1	2	0	/	/	/	/	/	11
Park SH et al. [38]	2	2	2	2	1	2	0	/	/	/	/	/	11
Suh et al. [36]	2	2	2	2	1	2	0	/	/	/	/	/	11
Saragas et al. [35]	2	2	2	2	1	2	0	1	2	2	2	2	20
Hu et al. [37]	2	2	2	2	1	2	0	/	/	/	/	/	11

). The comparison research ranged from 9 to 11, and for the non-comparative studies, it ranged from 19 to 20, with 11 being the mean number for both types of investigations.

5. Discussion

Peroneal tendon dislocation is a rare condition that is frequently misdiagnosed or underdiagnosed [7]. Even then, it is a severely disabling condition that usually affects young athletes during sporting activity. The mechanism of injury is insidious, often occurring by rapid contraction of the peroneal muscle during dorsiflexion of an everted foot or after acute inversion injury of a dorsiflexed ankle. The purpose of this study is to determine which surgical procedure for peroneal tendon dislocation allows patients to return to sports faster with a lower recurrence rate. According to a 2015 review, groove deepening + SPR repair is the best treatment for peroneal tendon dislocation [19]. Reattaching the superior retinaculum is the most suitable technique when using an anatomical approach [17,39,40,41,42].

We divided patients from the different studies reviewed into five groups (A, A+, B, C, and D). This division allowed us to distinguish patients treated with different surgical procedures. As for the rate of return to sport, we can assess that the Group A+ and D patients had the highest rate of return to sport after surgical treatment compared to the others (100%). We cannot state that these surgical treatments are the best ones because the number of patients enrolled is too low, so they are not reliable.

The RTS rate among group A and B patients is more reliable according to a higher sample: group A 155, group B 179. They showed a 93.5% rate of RTS in Group A and a 99.4% rate of RTS in Group B. We can state the same for the AOFAS score, VAS scale, Satisfaction, and Redislocation. This shows that our findings are in line with the current literature. New surgical techniques described, such as group A+, C, and D, show excellent results. Maybe a longer follow-up, in addition to new studies focused on these techniques, will show better results than the existing one.

A noninvasive technique through an endoscopic approach can give the same outcomes as an open operation [43,44,45]. Anchors were used for SPR reattachment, similar to arthroscopic repair of Bankart lesions of the shoulder [46,47].

Adachi and associates published the outcomes of 18 SPR reattachment cases using a tension-tissue device to increase retinal tension. At two years, all had fully recovered and returned to pre-injury activity levels [26].

Zoellner and Clancy described a method to widen the groove through excision and localized bone excavation [48]. In 14 cases, Porter and colleagues described modifying this approach by receding the posterior cortex and repairing the SPR. Instead of using the typical postoperative cast immobilization, a walking boot was employed along with physiotherapy beginning one week after surgery. At three years, there were no recurrences, few surgical side effects, and an average three-month return to sports [25]. The use of the calcaneofibular ligament is a good way to hold the tendons in place, which is a good alternative to direct SPR repair [49,50,51].

Shawen and Anderson refined the technique to prevent complications. They proposed to ream out the fibular core from the tip parallel to the retromalleolar groove to thin the cortical rim. Afterward, the cortical rim is impacted to obtain a better result [52,53].

Other techniques, such as the use of the anterior part of the peroneus brevis tendon as described by Chrisman and Snook [54,55], showed good but not better results than direct SPR repair and groove deepening.

Conservative treatment showed a very low (<50%) success rate with nonsurgical treatment in patients with chronic injuries [18,56,57].

Controversial ideas exist in the literature about the role of conservative treatment. There is concern that if these injuries are left untreated, the traction line in the dislocated position will cause adaptive shortening of the fibulae, resulting in loss of power in the stride phase and weakness in valgus. This can predispose patients to serious injuries [58]. Almost half of the patients analyzed required surgery [59].

The surgical treatment of acute injuries showed excellent results and a rapid recovery [50,60,61,62].

Hume et al. in 1920 described the first bone block procedure. These types of procedures require the creation of a posterior lip to prevent subluxation or dislocation of the peroneal tendons [63].

Some patients are not eligible or refuse to undergo surgery, so it is important to know the clinical outcomes of non-surgical interventions [64]. Taping, compressive bandages, and early mobilization are associated with a high rate of recurrent dislocation [18,59].

The most important result of this study is that groove deepening with SPR repair and isolated SPR repair are both successful treatments for peroneal tendon dislocation.

SPR repair associated with groove deepening showed a higher rate of return to sport in patients treated with isolated SPR repair, making it the recommended treatment in the sports population [19,35,37]. Although this result is based on limited evidence due to a lack of high-quality studies.

In this study, we compared five different types of treatment for peroneal tendon dislocation.

Group A: patients treated with SPR repair alone [1,24,26,32,34,38];

GROUP A+: patients treated with groove deepening using low-profile snap-off screws [36];

GROUP B: patients treated with groove deepening and SPR repair [16,23,25,27,28,29,31,34,35,37].

A few studies reported on patients treated with bony procedures (GROUP C) [32,33] and rerouting procedures (GROUP D) [30].

The group that reported the highest improvement in the AOFAS score is GROUP B. The group that reported the worst improvement in the AOFAS score is GROUP A+—preoperative AOFAS: 69.96 ± 13.14 (45 to 88); postoperative AOFAS: 87.72 ± 10.13 (58 to 100).

There were 105 out of 171 patients who rated their satisfaction as excellent, 50 out of 171 as good, and 15 out of 171 as fair or poor; 1 out of 171 was uncertain.

The study that reported the best improvement of the VAS scale is by Zhenbo et al., where the preoperative VAS scale was 7.4 and the postoperative VAS scale was 1.4 [33].

The groups with the highest rate of return to sport are GROUP A and GROUP B (about 100% in both groups), but the same groups reported the highest number of cases of redislocation: GROUP A (three out of seven cases of redislocation) and GROUP B (three out of seven cases of redislocation).

The surgical management of peroneal tendon dislocation has only been the subject of one previous systematic review [65]. A different study by Oliva et al. determined that SPR repair is the best surgical remedy for peroneal tendon subluxation, but because it was not founded on a methodical evaluation of studies that had been collected, there was insufficient evidence to support their conclusions [3].

This study is not without limitations; in fact, we have a low number of high-quality studies, which means low reliability of the results obtained. Moreover, we have a risk of selection bias due to a lot of studies with a high prevalence of lateral ankle comorbidities among the patients enrolled.

6. Future Prospects

Other studies with a higher quality level that enroll a larger number of patients would yield better results.

7. Conclusions

Surgical treatment with SPR repair alone and SPR repair + groove deepening showed good and reliable results. In fact, they reported a good improvement in the AOFAS score and the VAS scale and a high level of satisfaction among patients treated. The other surgical treatments, such as groove deepening using low-profile snap-off screws, bony procedures, and rerouting procedures, analyzed showed good results, but there is low reliability in these data due to the low quantity of studies present in the literature. In conclusion, all the surgical treatments allowed the majority of patients to return to sports in a short time.