Peroneal tendoscopy for peroneal tendon disorders: A systematic review of indications, diagnostic utility, and clinical outcomes.

Abstract

Peroneal tendon disorders span tendinopathy, tenosynovitis, intrasheath subluxation, stenosis, and tears, and may be challenging to diagnose accurately with clinical examination and MRI alone. Peroneal tendoscopy offers a minimally invasive, diagnostic-therapeutic option. We systematically reviewed clinical indications, intraoperative findings, procedures, imaging accuracy, complications, and patient-reported outcomes following peroneal tendoscopy. Eight studies (190 patients; 195 ankles) were reviewed. Data on demographics, indications, procedures, PROMs, return to sport (RTS), complications/failures, and imaging-tendoscopy agreement were extracted and pooled when constructs aligned. Random-effects meta-analyses generated pooled means or proportions with 95 % CIs (Hartung-Knapp adjustment). Where applicable, diagnostic performance of preoperative assessment was compared with tendoscopy as reference. Across 190 patients (195 ankles), pooled mean age was 32 years (95 % CI 25.0-39.0), follow-up 30.3 months (95 % CI 20.8-39.8); 71 % of ankles had traumatic aetiologies. Indications were broad, with recurrent subluxation/dislocation, intrasheath subluxation, and refractory lateral ankle pain common. Frequently performed procedures included synovectomy/debridement (94 ankles), groove deepening (34 ankles), excision of space occupying lesions (65 ankles; predominantly low-lying muscle bellies [LLMB] and peroneus quartus), tendon repair/tubularization (23 ankles), and tendoscopic retinacular repair (14 ankles). Six studies reported validated PROMS with four reporting AOFAS suitable for pooling. Postoperative AOFAS averaged 96.6 (95 % CI 94.3-99.0) with a pooled mean gain of +19.8 (95 % CI 18.5-21.2); JSSF, FAOS and SF-12 improved significantly. RTS occurred at a pooled 13.3 weeks (95 % CI 10.6-16.0), with RTS of 12.2 ± 0.6 weeks after tendoscopic retinacular stabilization and 14.8 ± 2.0 weeks after groove deepening. Overall complications were 7.6 % (13 events) and mainly consisted of persistent ankle pain and minor wound issues. Failure rate was 1.5 % and two revision surgeries (1.0 %) were reported. Diagnostic agreement was high at the aggregate level (MRI overall sensitivity 0.90, specificity 0.72), but lesion-level performance varied: MRI was strong for tears and tenosynovitis, weaker for stenosis. Composite preoperative diagnosis in a large series showed high specificity (0.97) but only moderate sensitivity (0.76), with LLMB frequently under-recognized preoperatively. Peroneal tendoscopy provides meaningful functional gains, timely RTS, and a low adverse-event burden across a wide indication spectrum, and it complements imaging by clarifying dynamic/space-conflict pathology. Longer, prospective comparative studies are warranted.