Staged Reconstruction for Chronic Rupture of Both Peroneal Tendons Using Hunter Rod and Flexor Hallucis Longus Tendon Transfer

  • Christy M. Christophersen
  • Osama Elattar
  • Keith L. WapnerEmail author


Chronic lateral ankle pain can have many different etiologies. Peroneal tendon pathology is a major cause. Fissuring and longitudinal splitting of the peroneus brevis and longus tendons have been reported as a common etiology for chronic lateral ankle pain and functional instability. Patients with advanced pathology who have failed both primary repair and anastomosis of peroneus brevis and longus present a surgical challenge, especially in young active patients where the goal is to achieve dynamic stabilization of the ankle and to restore peroneal tendon function. Staged reconstruction using a Hunter rod and the flexor hallucis longus (FHL) tendon has been described as a salvage procedure for treatment of chronic ruptures of both peroneal tendons. The first stage involves debridement of the remaining portion of the peroneal tendons and sheath followed by implantation of a Hunter rod to the insertion of the peroneus brevis. Passive range-of-motion exercises for 3 months are allowed before removal of the Hunter rod. The second stage involves removal of the Hunter rod and transfer of the flexor hallucis longus (FHL) into the newly formed sheath, attaching it to the insertion of the peroneus brevis on the fifth metatarsal base.


Peroneal tendon Chronic rupture Staged reconstruction Hunter rod Flexor hallucis longus tendon transfer 


  1. 1.
    Bassett F, Speer K. Longitudinal rupture of the peroneal tendons. Am J Sports Med. 1993;21:354–7.PubMedGoogle Scholar
  2. 2.
    Brage ME, Hansen ST. Traumatic subluxation/dislocation of peroneal tendon. Foot Ankle. 1992;13:423–31.PubMedGoogle Scholar
  3. 3.
    Burman M. Stenosing tendovaginitis of the foot and ankle studies with special reference to the stenosing tendovaginitis of the peroneal tubercle. AMA Arch Surg. 1953;67:686–98.PubMedGoogle Scholar
  4. 4.
    Cox D, Paterson F. Acute calcific tendonitis of the peroneus longus. J Bone Joint Surg. 1991;73-B:342.Google Scholar
  5. 5.
    Davies J. Peroneal compartment syndrome secondary to rupture of the peroneus longus. J Bone Joint Surg. 1979;61-B:783–4.Google Scholar
  6. 6.
    Eckert WR, Davis EA Jr. Acute rupture of the peroneal retinaculum. J Bone Joint Surg. 1976;58:A:670–2.PubMedGoogle Scholar
  7. 7.
    Edwards ME. The relations of peroneal tendon to the fibula, calcaneus, and cuboideum. Am J Anal. 1928;42:213–53.Google Scholar
  8. 8.
    Evans J. Subcutaneous rupture of the tendon of the peroneus longus: a case report. J Bone Joint Surg. 1966;48:B:507–9.Google Scholar
  9. 9.
    Frey C, Shereff M, Greenidge N. Vascularity of posterior tibial tendon. J Bone Joint Surg. 1990;72-A:884–8.Google Scholar
  10. 10.
    Hunter JM, Salisbury R. Flexor Tendon reconstruction in severely damaged hand: a Two Stage Procedure using a Silicone-Dacron reinforced Gliding prosthesis prior to tendon Grafting. J Bone Joint Surg. 1971;53-A:829–58.Google Scholar
  11. 11.
    Imbriglia JE, Hunter J, Rennie W. Secondary Flexor Tendon Reconstruction. Hand Clin. 1989;5:395–413.PubMedGoogle Scholar
  12. 12.
    Karlsson J, Brandsson S, Kalebo P, Eriksson BI. Surgical treatment of concomitant chronic ankle instability and longitudinal rupture of the peroneus brevis tendon. Scand J Med Sci Sports. 1998;8(1):42–9.PubMedGoogle Scholar
  13. 13.
    Kilkelly FX, McHale KA. Acute rupture of the peroneal longus tendon in a runner: a case report and review of the literature. Foot Ankle Int. 1994;15:567–9.PubMedGoogle Scholar
  14. 14.
    Krause JO, Brodsky JW. Peroneus Brevis tears: pathophysiology and surgical reconstruction and clinical results. Foot Ankle Int. 1998;19:271–9.PubMedGoogle Scholar
  15. 15.
    Larsen E. Longitudinal rupture of the peroneus brevis tendon. J Bone Joint Surg. 1987;69-B:340–1.Google Scholar
  16. 16.
    La Salle WB, Strickland JW. An evaluation of two stage flexor tendon reconstruction technique. J Hand Surgery. 1983;8:263–7.Google Scholar
  17. 17.
    Le Melle DP, Janis R. Longitudinal rupture of the peroneus brevis tendon: a study of eight cases. J Foot Surg. 1989;28:132–6.Google Scholar
  18. 18.
    Meyer AW. Further evidence of attrition in the human body. Am J Anat. 1924;34:324–67.Google Scholar
  19. 19.
    Munk RL, Davis PH. Longitudinal rupture of the peroneus brevis tendon. J Trauma. 1976;16:803–6.PubMedGoogle Scholar
  20. 20.
    Parvin RW, Fort TL. Stenosing tenosynovitis of the common peroneal tendon sheath. J Bone Joint Surg. 1956;38-A:1352–7.PubMedGoogle Scholar
  21. 21.
    Pelet S, Saglini M, Garofalo R, Wettstein M, Mouhsine E. Traumatic rupture of both peroneal longus and brevis tendons. Foot Ankle Int. 2003;24:721–3.PubMedGoogle Scholar
  22. 22.
    Purnell ML, Drummond DS, Engber WO, Breed AL. Congenital dislocation of peroneal tendon. J Bone Joint Surg. 1983;65-B:316–9.Google Scholar
  23. 23.
    Regan TP, Hughston JC. Chronic ankle sprain secondary to anomalous peroneal tendon. Clin Orthop. 1977;123:52–4.Google Scholar
  24. 24.
    Sammarco GJ, DiRaimondo CV. Chronic peroneus brevis tendon lesions. Foot Ankle. 1989;9:163–70.PubMedGoogle Scholar
  25. 25.
    Sammarco GJ, DiRaimondo CV. Surgical treatment of lateral ankle instability. Am J Sports Med. 1988;16:501–11.PubMedGoogle Scholar
  26. 26.
    Silver RL, deLa Garza J, Rang M. The myth of muscle balance: A study of relative strength and excursions of normal muscle about the foot and ankle. J Bone Joint Surg. 1985;67-B:432–7.Google Scholar
  27. 27.
    Sobel M, Bohne WHO, Markisz JA. Cadaver correlation of peroneal tendon changes with magnetic resonance imaging. Foot Ankle. 1991;11:384–8.PubMedGoogle Scholar
  28. 28.
    Sobel ML, DiCarlo EF, Bohne WHO, Collins L. Longitudinal splitting of peroneus brevis tendon: An anatomic and histologic study of cadaveric material. Foot Ankle. 1991;12:165–70.PubMedGoogle Scholar
  29. 29.
    Sobel M, Geppert MJ. Repair of concomitant lateral ankle ligament instability and peroneus brevis split through a posteriorly modified Brostom Gould. Foot Ankle. 1992;13:224–5.PubMedGoogle Scholar
  30. 30.
    Sobel M, Geppert MJ, Hannafin JA, Bohne WH, Arnoczky SP. Microvascular anatomy of the peroneal tendons. Foot Ankle. 1992;13:469–72.PubMedGoogle Scholar
  31. 31.
    Sobel M, Geppert MJ, Olson E, Bohne WH, Arnoczky SP. The dynamics of peroneus brevis tendon splits: a proposed mechanism, techniques of diagnosis, and classification of injury. Foot Ankle. 1992;13:413–22.PubMedGoogle Scholar
  32. 32.
    Sobel M, Levy M, Bohne WH. Congenital variations of peroneus quartus muscle: an anatomic study. Foot Ankle. 1990;11:81–9.PubMedGoogle Scholar
  33. 33.
    Sobel M, Levy M, Bohne WH. Longitudinal attrition of peroneus brevis tendon in the fibular groove: an anatomic study. Foot Ankle. 1990;11:124–8.PubMedGoogle Scholar
  34. 34.
    Sobel M, Warren RF, Brourman S. Lateral ankle instability associated with dislocation of peroneal tendon treated by a modified Chrisman-Snook procedure: a new technique and review of literature. Am J Sports Med. 1990;18:539–43.PubMedGoogle Scholar
  35. 35.
    Thompson F, Patterson A. Rupture of the peroneus longus tendon: report of three cases. J Bone Joint Surg. 1989;71-A:293–5.Google Scholar
  36. 36.
    Wapner KL, Pavlock GS, Hecht PJ, Naselli F, Walther R. Repair of Chronic Achilles Tendon Rupture with Flexor Hallucis Longus Tendon Transfer. Foot Ankle. 1993;14:443–9.PubMedGoogle Scholar
  37. 37.
    Wapner KL, Dalton GP. Repair of chronic Achilles tendon rupture with flexor hallucis longus transfer. Op Tech Orthop. 1994;4:132–6.Google Scholar
  38. 38.
    Webster FS. Peroneal tenosynovitis with pseudotumor. J Bone Joint Surg. 1968;50-A:153–7.Google Scholar
  39. 39.
    Wehbe MA, Mawr B, Hunter JM, Schneider LH, Goodwyn BL. Two-stage flexor tendon reconstruction. J Bone Joint Surg. 1986;68- A:752–63.Google Scholar
  40. 40.
    Weinstein SL, Sprague BL, Flatt AE. Evaluation of two stage flexor tendon reconstruction in severely damaged digits. J Bone Joint Surg. 1976;58A:786–91.Google Scholar
  41. 41.
    Wapner KL, Taras JS, Lin SS, Chao W. Staged reconstruction for chronic rupture of both peroneal tendons using Hunter rod and flexor hallucis longus tendon transfer: a long-term followup study. Foot Ankle Int. 2006;27(8):591–7.PubMedGoogle Scholar
  42. 42.
    Redfern D, Myerson M. The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int. 2004;25(10):695–707.PubMedGoogle Scholar
  43. 43.
    Mook WR, Parekh SG, Nunley JA. Allograft reconstruction of peroneal tendons: operative technique and clinical outcomes. Foot Ankle Int. 2013;34(9):1212–20.PubMedGoogle Scholar
  44. 44.
    Borton DC, Lucas P, Jomha NM, Cross MJ, Slater K. Operative reconstruction after transverse rupture of the tendons of both peroneus longus and brevis: surgical reconstruction by transfer of the flexor digitorum longus tendon. J Bone Joint Surg. British volume. 1998;80(5):781–4.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Christy M. Christophersen
    • 1
  • Osama Elattar
    • 2
  • Keith L. Wapner
    • 3
    Email author
  1. 1.Department of Orthopaedic SurgeryMayo ClinicRochesterUSA
  2. 2.Department of Orthopaedic SurgeryUniversity of Toledo Medical CenterToledoUSA
  3. 3.Department of Orthopaedic SurgeryPenn MedicinePhiladelphiaUSA

Personalised recommendations