Foot & Ankle International - September 2019 - 1015

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Sherman et al
possible over 10 seconds on both sides following a practice
trial and a rest period prior to measurement.
A 2-tailed, paired Student t test was used for all statistical
comparisons, with significance reported for P values less
than .05 and standard deviation reported in parentheses.

Results
All 17 patients reported satisfaction with their surgical outcome. Thirteen of 17 reported they were "very satisfied," 3
reported that they were "satisfied," and 1 was "somewhat
satisfied." Nine of 17 reported their outcome as "excellent,"
and 8 of 17 as "good." All patients reported that they would
recommend the surgery to someone with a similar problem.
None reported new limitations after their surgery. Four of 17
reported that they intermittently wear an ankle support brace.
Two patients could not return for examination because
of distance. Of 15 patients examined, 8 patients had varus
heel alignment postoperatively. Three of 15 patients had
increased figure-of-eight measurements at the ankle compared with the contralateral side, indicating fullness or
edema. Seven of 15 patients had a decrease in calf circumference relative to the contralateral side. The mean magnitude of decreased calf circumference of those with atrophy
was 1.6% ± 0.8% (range, 0.5%-3.0%). Eight of 15 patients
had restricted dorsiflexion motion compared with the contralateral side with a mean restriction in dorsiflexion compared with the contralateral side of 31.9% ± 20.0% (range,
14.3%-69%). Four of 15 patients had decreased plantarflexion on the operative side compared with the unaffected side
with a mean percentage difference of 22.7% ± 21.5%
(range, 5.4%-51.4%). Eight of 15 patients had diminished
eversion motion compared with the contralateral side of
58.2% ± 37.2% (range, 17%-133%) relative to the contralateral limb. Nine of 15 patients had less inversion motion
compared with the contralateral side, with a mean decrease
of 24.4% ± 18.4% (range, 1.9%-62.5%).
Nine of 15 patients had diminished isometric peak torque
on the affected side relative to the unaffected contralateral
limb with an average decrease of 38.4% ± 22.1% (range,
2.8%-71.1%). Thirteen of 15 produced less isotonic peak
velocity on the operative limb with an average decrease of
28.8% ± 14.6% (range, 15.0-56.1) relative to the contralateral side. Thirteen of 15 patients had diminished power on
the operative limb with a mean difference in the operative
limb of 56.1% ± 15.8% (range, 30.8%-80.9%).
The average VAS pain level was 6.4 ± 3.3 preoperatively and 1.1 ± 1.5 (range, 0-4) at final follow-up. All
patients reported a reduction in their pain level with an
average decrease in VAS of 5.59 ± 2.5 (range, 1-9). The
average FAAM was 86.4 ± 9.7 (range, 52.4-100). The average FFI was 12.8 ± 9.2 (range, 0-21.4). The mean SMFA
Function Index was 12.4 ± 8 and the mean SMFA
Bothersome Index was 11.5 ± 11 (Table 1).

One of 17 patients had a postoperative complication,
which was a wound infection. The infection was related to
screw fixation of the calcaneus and resolved with hardware
removal and oral antibiotics.

Discussion
Concomitant irreparable rupture of the peroneal tendons is
an uncommon clinical problem that presents a unique surgical challenge. The results of this retrospective review support our hypothesis that FDL transfer would be a safe and
effective surgical technique for irreparable tears of both
peroneal tendons. The operative algorithm for peroneal tendinopathy has been outlined in the literature. Redfern and
Myerson recommend allograft reconstruction when there is
adequate muscle excursion and flexor tendon transfer when
there is significant muscle scarring.2,7,11,13 However, excursion is difficult to assess intraoperatively and muscle atrophy is often associated with chronic tears, which limits the
success of allograft reconstruction.5,13-15 Therefore, the FDL
tendon has been utilized for lateral transfer, given its similar
excursion and work percentage compared with the PB
tendon.16 Transfer can be done as a 1-stage or 2-stage reconstruction using silicone Hunter rods, which may be indicated when tissue damage has led to loss of an adequate
tendon sheath.13,21 Single-stage transfers of the FDL or FHL
tendon for treatment of concomitant, irreparable peroneal
tendon tears have shown good results in limited patient
series.3,5,7,8,12-14,17,18 Our study represents the largest cohort
detailing the outcomes of this procedure.
Borton and colleagues were the first to report FDL transfer to the PB in 2 patients with transverse tears of both
tendons.3 At 6 and 8 years of follow-up, the authors reported
excellent function with return to desired activities, including competitive golf. Jockel and Brodsky reported the
results of 8 patients in which the FHL or FDL tendon
was transferred for irreparable tears of both the PB and PL
tendons.8 At a mean follow-up of 58 months, all patients
had improved American Orthopaedic Foot & Ankle Society
(AOFAS) hindfoot scores, reported less pain, and expressed
overall satisfaction with their treatment. Subsequently,
Redfern and Myerson further defined the utility of tendon
transfer for peroneal tendinopathy.12 They advocated the
use of lateral tendon transfer in situations in which both tendons were diseased with no muscle belly excursion proximally. Four patients in their cohort of 28 patients underwent
an FDL tendon transfer with improved AOFAS scores in
each patient. More recently, Seybold and colleagues
reported outcomes of tendon transfer to the lateral foot for
peroneal tendinopathy in a large cohort.15 Nine patients
underwent lateral transfer of the FHL or FDL tendon for
concomitant PB and PL tears. The outcomes of 8 of the 9
patients were reported by the SF-12 and FFI, and 7 patients
returned for range of motion assessment, balance tests, and

Foot & Ankle International - September 2019

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