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Background: Recently the peroneus longus tendon (PLT) gained popularity in anterior cruciate ligament (ACL) reconstruction and has been utilized with satisfactory outcomes. However, there are concerns regarding donor site morbidity. This study aims to compare the functional outcome of ACL reconstruction using hamstring (HT) and PLT autografts and evaluate the donor site morbidity. Methods: Patients who underwent ACL reconstruction were allocated to two groups (HT and PLT). Graft diameter was measured intraoperatively. Knee functional outcome was evaluated with IKDC and Tegner-Lysholm scores preoperatively, and postoperatively after 3 months, 6 months, and 1 year. Donor site morbidities were assessed with thigh circumference measurements, subjective evaluation of sensory disturbances, and ankle scoring with AOFAS and FADI scores. Results: At 1-year follow-up, the PLT group showed comparable IKDC (p = 0.925) and Tegner-Lysholm (p = 0.600) scores with those of the HT group. The mean graft diameter in the PLT group (7.93 ± 0.52 mm) was larger compared with the HT group (7.43 ± 0.50 mm) (p < 0.001). The incidence of thigh atrophy (HT-16.7%, PLT-10%) and sensory disturbances (HT-73.3%, PLT-10%) was greater in the HT group. There was no significant ankle donor site morbidity in the PLT group (AOFAS-98.67 ± 3.45, FADI-99.23 ± 1.69). Conclusion: ACL reconstruction with PLT had comparable functional outcome with that of HT at 1 year. However, PLT demonstrated larger graft diameter, less donor site morbidity, and enhanced muscle recovery without significantly affecting the ankle function. PLT can be safely used as an acceptable alternative graft choice harvested from outside the knee for ACL reconstruction.

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The hamstring tendon (HT) autograft is currently the most widely utilised autograft option for anterior cruciate ligament (ACL) reconstruction. However, recent studies endorse the peroneus longus tendon (PLT) autograft as a viable alternative. To evaluate this, we systematically reviewed randomised controlled trials (RCTs) to compare the efficacy of PLT against HT autografts. Our search encompassed Cochrane, Embase, OVID, PubMed, and Scopus databases for RCTs comparing outcomes of PLT and HT autografts in ACL reconstruction. Primary outcomes included Lysholm and International Knee Documentation Committee (IKDC) scores, while secondary outcomes involved American Orthopaedic Foot and Ankle Society (AOFAS) scores, graft diameters and donor-site complications. Statistical analysis was performed using Review Manager 5.4 (Cochrane Collaboration) and heterogeneity was assessed with I2 statistics. 683 patients from 6 RCTs were included, with 338 (49.5%) patients treated with PLT autografts. Follow-up ranged from 12 to 30 months. Despite lower preoperative Lysholm scores in the PLT group, no significant differences were observed at 6 and 12 months. Although preoperative and 6-month IKDC scores were lower in the PLT group, no significant differences were found at 12 and 24 months. AOFAS scores showed no significant preoperative difference, but slightly lower scores were noted in the PLT group at 12 or 24 months. There was no significant difference in graft diameter, while donor-site complications were fewer in the PLT group. In summary, the PLT autograft is a promising and non-inferior alternative to the HT autograft, demonstrating equivalent outcomes in patient-reported knee and ankle metrics, comparable graft diameters and fewer donor-site complications.

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OBJECTIVE: Peroneus Longus Tendon (PLT), a viable anterior cruciate ligament (ACL) graft, shares similar biomechanics, making it suitable for reconstruction. Controversy exists over whether PLT transplants affects the donor ankle joint. The purpose of this study was to examine the recovery of knee joint function following arthroscopic ACL restoration using autologous PLT and its influence on the donor ankle joint. METHODS: A retrospective analysis was conducted on 65 patients with ACL rupture who underwent PLT graft reconstruction in our hospital from January 2016 to December 2021. A three-dimensional gait analysis of the bilateral knee and ankle joints was performed postoperatively using an Opti_Knee three-dimensional motion measurement and analysis system-Yidong Medical Infrared Motion Gait Analyzer. Knee function scores and changes in the range of motion of the bilateral knee and ankle joints were collected. The analysis of preoperative and postoperative joint function scores, bilateral knee and ankle mobility was performed by t-tests. RESULTS: One year after surgery, the patients' International Knee Documentation Committee (IKDC) scores, Knee Injury and Osteoarthritis Outcome Scores (KOOSs), and Lysholm scores were significantly improved compared to preoperative scores, with statistically significant differences (p < 0.05). There was no statistical difference in the American Orthopedic Foot and Ankle Society (AOFAS) score of the donor ankle joint before and after surgery (p > 0.05). During different gait cycles, there was no statistical difference in knee joint mobility between the affected and healthy sides (p > 0.05), but there was a statistical difference in the inversion and eversion angle of the donor ankle joint during the support phase (p < 0.05). CONCLUSION: ACL reconstruction using the PLT can yield satisfactory knee joint function. However, it does affect inversion and eversion in the donor ankle joint, necessitating postoperative exercises. Similar subjective function ratings for both operated and non-operated feet, despite increased inversion-eversion motion in the operated foot, may be influenced by the subjective nature and margin of error in the AOFAS Ankle-hindfoot score, along with the relatively small variation in ankle inversion-eversion angles.

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Objectives: There is a paucity of comparative studies on the Peroneus longus tendon versus conventional hamstring autograft use in primary single-bundle ACL reconstruction. To date, there are no studies that reported donor ankle functional outcomes when a peroneus longus graft is harvested without performing a tenodesis to peroneus brevis. Methods: A single-center retrospective comparative study was undertaken to evaluate the functional outcomes (IKDC & Tegner-Lysholm scores) of primary isolated single bundle anatomic ACL Reconstruction with Peroneus Longus tendon (PL group) versus Hamstring (HT group) autografts. Further, an evaluation of donor ankle morbidity using the AOFAS score for the PL group and persistent anteromedial thigh pain and paraesthesia around the knee for the HT group was also performed. Results: 30 patients were evaluated in each group. The mean graft diameter was 8.61 +/- 0.66mm (HT) & 9.6 +/- 0.84mm (PL) and the mean graft length was 7.39cm (HT) & 7.86cm (PL) respectively. The mean IKDC scores were 58.2 (Pre-op) & 89.52 (1 year) for the HT group and 61.8 (Pre-op) & 90.9 (1 year) for the PL group respectively. The mean Tegner-Lysholm scores were 69.83 (Pre-op) & 91.96 (1 year) for the HT group and 70.66 (Pre-op) & 92.36 (1 year) for the PL group respectively.10% of the HT group had residual anteromedial thigh pain & 6.7% had paraesthesia at one-year follow-up. In the PL group, the mean AOFAS score was 96.37 +/- 2.49 at the end of one year. Two cases (6.66%) reported paraesthesia around the harvested site. Conclusion: Peroneus longus tendon appears to be a better autograft choice than hamstrings for primary ACL reconstruction. Further, without a peroneal tenodesis, the functional outcomes of the donor ankle remained excellent.

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BACKGROUND AND OBJECTIVES: In anterior cruciate ligament reconstruction, the strength of the graft was found to be unsatisfactory usually the anterior half of the peroneus longus tendon was taken for supplementation, but the effect on foot and ankle function and gait in the donor area is unclear. This study aims to explore the changes in the ankle and gait after using the harvested anterior half of the peroneus longus tendon as a reconstruction graft for the anterior cruciate ligament. METHODS: A total of 20 patients, 6 males and 14 females, aged 18 to 44 years, with unilateral anterior cruciate ligament injuries, underwent reconstruction using the harvested anterior half of the peroneus longus tendon as a graft between June 2021 and December 2021. The part on which the anterior half of the peroneus longus tendon was harvested was considered the experimental group, while the contralateral foot was the control group. At the 6-month follow-up, the Lysholm knee score, AOFAS ankle score, and gait-related data (foot length, arch index, arch volume, arch volume index, and gait cycle parameters: percentage of time in each gait phase, step frequency, step length, foot strike angle, and push-off angle) were assessed using a 3D foot scanner and wearable sensors for both groups. RESULTS: All 20 patients completed the six-month follow-up. There were no statistically significant differences between the experimental and control groups regarding knee scores, ankle scores, foot length, arch index, arch volume, arch volume index, step frequency, and step length (P > 0.05). However, there were statistically significant differences between the experimental and control groups in terms of the gait cycle parameters, including the percentage of time in the stance, mid-stance, and push-off phases, as well as foot strike angle and push-off angle (P < 0.05). CONCLUSION: Through our study of the surgical experimental group we have shown that harvesting the anterior half of the peroneus longus tendon does not affect foot morphology and gait parameters; however, it does impact the gait cycle.

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The os peroneum is an accessory ossicle located along the lateral aspect of the cuboid bone. Its position can serve as an indicator of peroneus longus tendon (PLT) injury. Imaging studies including radiographs and MRI can help detect malposition of the os peroneum and progressive injuries to the PLT and its associated structures. We report a case of a woman with recurrent foot and ankle pain, demonstrating progressive retraction of the os peroneum, implying severe PLT injury which may have ultimately predisposed her to a traumatic fifth metatarsal base fracture. This case highlights the importance of scrutinizing the appearance and position of the os peroneum on radiographs.

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PURPOSE: The use of peroneus longus tendon (PLT) autografts in primary anterior cruciate ligament reconstruction (ACLR) has increased recently, but there is a lack of research on its use in revision ACLR. This study aimed to compare the clinical outcomes and complications between revision ACLR using allografts and PLT autografts. MATERIALS AND METHODS: Fifty-nine patients who underwent arthroscopic revision of ACLR with complete clinical follow-ups between 2012 and 2021 were retrospectively reviewed. Allograft was used in 44 of these patients, and PLT autograft was used in 15 of them. Lysholm knee score, Tegner activity score, Lachman, and anterior drawer tests were performed after a mean follow-up of 60months (range: 19-116). The American Orthopaedic Foot and Ankle Society (AOFAS) scale was used to evaluate the donor ankle functions. Clinical outcomes and complications were compared between groups. RESULTS: Both groups showed significantly improved functional outcomes compared to their preoperative assessments. However, both groups had similar clinical results at the final follow-up, including Lysholm knee score, Tegner activity scale, knee range of motion, return to sports, time to return to daily activities, and rate of re-rupture. No major complications were seen in any of the patients. The AOFAS score was 99.13±2.64 in the PLT autograft group without loss of ankle muscle strength, deformity, instability, and permanent iatrogenic neurovascular injuries. The cumulative cost of the allograft group was significantly higher than the PLT autograft group. CONCLUSIONS: The PLT autograft might be an alternative autograft option to allografts due to similar clinical outcomes, low donor site morbidity, and reduced cost in ACLR revisions, especially if the primary ACLR was performed using grafts harvested around the knee. LEVEL OF EVIDENCE: III; retrospective comparative study.

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OBJECTIVE: Peroneus longus tendon (PLT) has become a reliable autologous graft option for various ligament reconstructions. But there are potential risks and complications associated with its use as a graft. This retrospective study aimed to examine the complications and donor site morbidity following PLT harvesting. PATIENTS AND METHODS: A retrospective review was performed on an institutional digital patient database, and all patients who underwent ligament reconstruction using PLT autograft were identified. Intraoperative, early, and late complications were reviewed using digital patient notes and patients underwent a complete physical examination during their final follow-up. Ankle function was assessed using the AOFAS score, and manual ankle muscle testing was performed on both sides. Sural nerve iatrogenic injury was evaluated with a dermatomal light touch examination. Cosmetic satisfaction due to incision scar and footwear complaints were also assessed. RESULTS: 82 patients (74 male, eight female) with a mean age of 31.9 ± 10.4 years (range, 16-66) were included in the final analysis. The mean follow-up time was 46.6 ± 30.3 months (range, 6-109). The mean AOFAS score for the donor side was 98.7 ± 3.3 (range, 87-100), and the contralateral side score was 100, with manual muscle testing graded as 5 in all movements and similar to the contralateral side. Fifteen patients (18.3%) had hypoesthesia over the dorsolateral aspect of the foot distal to the incision scar, two patients (2.4%) had hyperalgesia over the distal incision scar, and one patient (1.2%) had mild ankle instability. There were two cases (2.4%) of compartment syndrome, both of which were treated with fasciotomy and had complete regression of symptoms after 5 days. One patient (1.2%) had a transient peroneal nerve injury and foot drop that resolved in the sixth month. CONCLUSIONS: The results of this retrospective study suggest that harvesting the PLT is associated with a high rate of complications and donor site morbidity. The most common complication was hypoesthesia around the lateral side of the foot, although the ankle functions were not affected significantly. Two cases of compartment syndrome and one transient peroneal nerve injury were observed. Care should be taken while harvesting PLT autograft, and it should be kept in mind that peroneal nerve injury might occur. LEVEL OF EVIDENCE: Level IV, retrospective case series.

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BACKGROUND: Patellar dislocation is common in young people. Although isolated anatomic double-bundle reconstruction of the MPFL is a common and effective surgical treatment for patellofemoral instability, concerns about the risk of injury to the epiphysis remain. METHODS: A total of 21 children and adolescents (9 males, 12 females; mean age: 10.7 years; range: 8 to 13 years) with recurrent patella dislocation or symptomatic instability following a primary dislocation were enrolled in the study. In all patients, double-bundle medial patellofemoral ligament (MPFL) reconstruction and femoral sling procedure were performed under arthroscopy, using an anterior half peroneus longus tendon (AHPLT) autograft. Functional outcomes were evaluated preoperatively and during follow-ups based on Kujala and Lysholm scores. Radiological examinations including radiographs, 3D-CT, and MRI were performed pre- and post-operatively. RESULTS: Among two-year postoperative follow-up (range: 24-42 months) showed significant improvement in functional scores (p < 0.01). The Lysholm score increased from 68 (44.5) to 100 (0) and the Kujala score increased from 26 (34.5) to 100 (2) The patellar tilt angel improved significantly (p < 0.01) from 24.3° ± 10.4 preoperatively to 11.9° ± 7.0 postoperatively. MRIs performed 6- and 12-months post operation did not show any signs of dysfunction of the reconstructed MPFL or cartilage degeneration. STUDY DESIGN: Case Series; Level of evidence, 4. CONCLUSION: Arthroscopic reconstruction of the MPFL using the modified sling procedure is an effective procedure for the treatment of patellar instability in skeletally immature patients.

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Background Ever since the arthroscopic reconstruction of the anterior cruciate ligament (ACL) has begun, the use of the peroneus longus (PL) graft for primary ACL reconstruction (ACLR) has never been thought of. There is very little literature on it. Hence, our study aims to compare the functional outcomes, knee stability, donor site morbidity, and assessment of thigh muscle wasting in patients with ACL injury managed by arthroscopic single bundle reconstruction with peroneus longus tendon (PLT) and hamstring tendons (HT), respectively. Methods All adults aged 16-50 years of either gender presenting with symptoms of symptomatic ACL deficiency were admitted for arthroscopic single-bundle ACLR and allocated into two groups (peroneus longus and hamstring tendon). Functional scores (International Knee Documentation Committee (IKDC), Lysholm score), clinical knee evaluation (anterior drawer, Lachman, and pivot shift test), donor site morbidity (American Orthopedic Foot and Ankle Society ankle hindfoot score (AOFAS)), and thigh circumference were recorded preoperatively and at six months and one year postoperatively. The same post-op rehabilitation protocol was followed in both groups. Results One hundred and ninety-four patients (hamstring n = 96, peroneus n = 98) met the inclusion criteria. There were no significant differences between the preoperative, six-month postoperative, and one-year postoperative scores between the hamstring and peroneus longus groups in the IKDC (p=0.356) and Lysholm knee score (p=0.289). The mean for the AOFAS was 99.05 ± 3.56 and 99.80 ± 0.70 in the PLT and HT groups, respectively, showing no statistical difference, with a significant improvement in thigh muscle wasting among the PLT group at final follow-up (p < 0.001). Conclusion We observed similar knee stability and functional outcomes and no obvious donor site morbidity among both groups. These patients also had better responses to physiotherapy in recovering from their thigh muscle wasting. So, we can recommend that a PL graft can be a safe, viable, and effective option for usual arthroscopic single-bundle ACL reconstruction.

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Introduction: Harvesting peroneus longus for ACL reconstruction is thought to create ankle instability which could add to postural instability from an ACL injury. This apprehension prevents its use as a graft of primary choice for many surgeons. To date, there is no evidence available describing changes in postural control after its use in ACL reconstruction. The purpose of the study was to analyse the changes in postural control in the form of static and dynamic body balance after ACL reconstruction with Peroneus Longus Tendon Graft and compare it with the unaffected limb at different time intervals. Materials and methods: Thirty-one participants with ACL injury were selected and subjected to an assessment of static and dynamic balance before and after ACL reconstruction using the HUMAC balance system. Outcome measures for Centre of Pressure (COP) assessment were average velocity, path length, stability score, and time on target. Comparison of scores was done pre-operatively as well as at three- and six-months post-reconstruction with Peroneus longus tendon graft. Results: Static balance of the affected limb showed significant improvement with a decrease in average velocity (F=4.522, p=0.026), path length (F=4.592: p=0.024) and improvement of stability score (F=8.283, p=0.001). Dynamic balance measured by the time on the target variable also showed significant improvement at six-month follow-up (F=10.497: p=0.000). There was no significant difference between the affected and non-affected limb when compared at the different time intervals. Conclusion: The static and dynamic balance, which is impaired after ACL injury, improves with ACL reconstruction with PLT autologous graft. Hence PLTG can be safely used as a graft for ACL reconstruction without affecting postural control and body balance.

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PURPOSE: This study aimed to determine the correlation between the intraoperative diameter of double-stranded peroneus longus tendon (2PLT) and length of the PLT autograft and preoperative ultrasound (US) measurements, as well as radiographic and anthropometric measurements. The hypothesis was that US can accurately predict the diameter of 2PLT autografts during operation. METHODS: Twenty-six patients underwent ligament reconstruction with 2PLT autografts were included. Preoperative US was used to calculate the in situ PLT cross-sectional area (CSA) at seven levels (0, 1, 2, 3, 4, 5, 10 cm proximal to the harvest start point). Femoral width, notch width, notch height, maximum patellar length, and patellar tendon length were determined on preoperative radiographs. Intraoperative measurements of PLT were made, including all fiber lengths of PLT and diameters of 2PLT using sizing tubes calibrated to 0.5 mm. RESULTS: CSA at 1 cm proximal to the harvest site had the highest correlation with the diameter of 2PLT (r = 0.84, P < 0.001). Calf length had the highest correlation with PLT length (r = 0.65, P < 0.001). The diameter of the 2PLT autografts could be predicted by the following formula: 4.6 + 0.2 × [sonographic CSA of PLT at 1 cm level]; the length of PLT could be predicted by the following formula: 5.6 + 0.5 × Calf length. CONCLUSION: The diameter of 2PLT and length of PLT autografts can be accurately predicted by preoperative US and calf length measurements, respectively. Accurate preoperative prediction of the diameter and length of autologous grafts can provide the most suitable and individualized graft for patients. LEVEL OF EVIDENCE: IV.

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PURPOSE: To evaluate the distances using ultrasound between the superficial peroneal nerve (SPN) and sural nerve along the peroneus longus tendon (PLT) autograft harvest path at different ankle or knee positions in order to minimize risk of iatrogenic nerve injury during PLT autograft harvest. METHODS: Twenty-four fresh-frozen human cadaveric lower extremities were used to harvest a full-thickness PLT autograft with a tendon stripper. Four specimens were utilized to validate correct identification of nerves under ultrasound. Sonographically guided perineural injections were performed at the start point and end point of the PLT harvest path using coloured latex, followed by dissection with gross inspection. Using ultrasound, the distance from the peroneus brevis muscle to the sural nerve at different ankle positions (20° dorsiflexion, neutral, and 20° plantarflexion) was measured, and the distance from the end of the tendon stripper to the SPN at different knee positions (full extension and 90° flexion) was also measured. Measurements were performed by two separate observers using ImageJ software. RESULTS: Cadaveric dissection showed the presence of latex around nerves in all four specimens. The average distance from the brevis muscle to the sural nerve increased significantly from dorsiflexion to plantarflexion. The shortest distance from the tenodesis site to the sural nerve was 5.8 ± 1.7 mm. There was no significant difference from the end of the tendon stripper to the SPN between full extension or 90° flexion of the knee. CONCLUSION: When harvesting the PLT, it is recommended to place the ankle at plantarflexion. The knee at full extension or 90° flexion had no effect. Joint positions at the time of graft harvest should be monitored to reduce risks of iatrogenic nerve injury.

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@#Introduction: Harvesting peroneus longus for ACL reconstruction is thought to create ankle instability which could add to postural instability from an ACL injury. This apprehension prevents its use as a graft of primary choice for many surgeons. To date, there is no evidence available describing changes in postural control after its use in ACL reconstruction. The purpose of the study was to analyse the changes in postural control in the form of static and dynamic body balance after ACL reconstruction with Peroneus Longus Tendon Graft and compare it with the unaffected limb at different time intervals. Materials and methods: Thirty-one participants with ACL injury were selected and subjected to an assessment of static and dynamic balance before and after ACL reconstruction using the HUMAC balance system. Outcome measures for Centre of Pressure (COP) assessment were average velocity, path length, stability score, and time on target. Comparison of scores was done pre-operatively as well as at three- and six-months post-reconstruction with Peroneus longus tendon graft. Results: Static balance of the affected limb showed significant improvement with a decrease in average velocity (F=4.522, p=0.026), path length (F=4.592: p=0.024) and improvement of stability score (F=8.283, p=0.001). Dynamic balance measured by the time on the target variable also showed significant improvement at six-month follow-up (F=10.497: p=0.000). There was no significant difference between the affected and non-affected limb when compared at the different time intervals. Conclusion: The static and dynamic balance, which is impaired after ACL injury, improves with ACL reconstruction with PLT autologous graft. Hence PLTG can be safely used as a graft for ACL reconstruction without affecting postural control and body balance.

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Introduction: Many kinds of grafts were used for single-bundle reconstruction of the posterior cruciate ligament (PCL). Recently, the peroneus longus tendon (PLT) was used in some clinical reports. This study aimed to test the best position of the femoral insertion in the case of using PLT for PCL reconstruction. Methods: Seventeen fresh frozen cadaveric knees were randomized into three groups. Group AL (6 knees): the femoral insertion in PCL reconstruction was at the footprint center of the anterolateral bundle (ALB). Group PM (5 knees): at the footprint center of the posteromedial bundle (PMB). And group MC (6 knees) was at the midpoint of the center of the anterolateral bundle and posteromedial bundle. The PCL of all knees was cut and a PCL reconstruction procedure was performed with autologous peroneus longus tendon (PLT). The stability of each knee was tested in three conditions: PCL was intact, PCL was resected, and PCL was reconstructed. The KT-1000 machine was used to measure the maximum posterior displacement of the tibia under force with the knees at 0, 30, 60, 90, and 120 degrees of flexion. Results: Average posterior displacement of the tibia under force for intact PCL of group AL was 1.6 mm, group MC was 1.2 mm, and group PM was 1.3 mm. After PCL was resected, the knee laxity was increased remarkably: posterior displacement of the tibia of group AL was 8.9 mm, group MC was 9.4 mm, and group PM was 13.6 mm. After PCL was reconstructed, group AL was 1.5 mm, group MC was 2.0 mm, and group PM was 5.6 mm. The results showed that after PCL reconstruction the group AL and group MC give better stability to the knee (p < 0.05, except knee at 120 degrees of flexion). Group AL got more stability than group MC, but the difference was not significant (p ≥ 0.164). Conclusion: In a single-bundle reconstruction of the PCL with the graft PLT, the femoral insertion at the footprint center of the ALB and the midpoint of the center of the ALB and PMB showed better stability than that at PMB.

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INTRODUCTION: The present study was done to analyze the functional outcome, donor site morbidities, and associated parameters when using the anterior half of the peroneus longus for augmentation of an inadequate hamstring graft when performing arthroscopic anterior cruciate ligament (ACL) reconstruction. METHODS: Thirty patients with complete ACL tears were operated on. In all these patients, the thickness or length of the hamstring graft taken was found to be inadequate (less than 8 mm and 7.5 cm, respectively). So, additionally, the anterior half of the peroneus longus tendon (AHPLT) graft was harvested to reach an optimum size of the final graft. Functional outcome was assessed using the International Knee Documentation Committee (IKDC) score at six weeks, three months, and six months. The Foot and Ankle Disability Index (FADI) score at six months was used to assess ankle stability. RESULTS: The mean age in our study was 28.8 years with male predominance (73.33%). The mean operative time was 86.4 minutes. The mean hamstring graft thickness in our study was 6.5 mm, which improved to 9.12 mm after augmentation. The mean graft length after AHPLT augmentation was 9.38 cm. The mean IKDC score at six months was 87.35. At the end of six months, FADI scores were found within normal limits (range: 135-136) in all the patients. No complications were noted in any of the patients. CONCLUSION: The AHPLT graft was always found to be sufficient enough for augmenting the hamstring graft to reach an acceptable thickness and length. There was no graft site morbidity and the ankle functional levels remained the same as preoperative levels, making it an excellent choice for augmentation of inadequate hamstring grafts.

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Background: Peroneus longus tendon can be a suitable alternative autograft for anterior cruciate ligament reconstruction (ACLR). The present study aimed to compare the clinical outcome and donor site morbidity in ACLR using peroneus longus tendon autograft versus hamstring tendon autograft. Methods: In a comparative cross-sectional study, ACLR was performed with quadrupled hamstring tendon autograft in 65 patients between 2017 and 2018, and in another group, peroneus longus tendon autograft was used for ACLR in 65 patients between 2018 and 2019. The same surgical technique, fixation method, and postoperative protocol were used in both groups. The knee functional outcomes were assessed according to the Lysholm score and the International Knee Documentation Committee scale at preoperative and at the end of at least 2 years after the procedure. Moreover, graft diameter was measured intraoperatively. Thigh circumference, the American Orthopedic Foot and Ankle Score (AOFAS), The Foot & Ankle Disability Index (FADI), and ankle range of motion (ROM) were used to evaluate ankle donor site morbidities. Results: A total of 130 patients (65 patients in each group) were evaluated with a minimum follow-up of 2 years (range 24-31 months). Both groups showed no significant differences in clinical outcomes and knee stability. The peroneus longus graft diameter was significantly larger than the hamstring diameter (P<0.001). Assessment of AOFAS, FADI, and ankle ROM showed no apparent ankle joint dysfunction in the peroneus longus tendon group. Conclusion: Faster knee extensions, less anteromedial knee pain, and thigh hypotrophy were observed in peroneus longus tendon patients. Peroneus longus tendon autograft can be an appropriate autograft for ACLR due to its strength, larger graft diameter, and avoiding potential complications of hamstring autograft obtained from the knee region.

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LEVELS OF EVIDENCE: Level IV: Case Series.

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Reconstruction of the anterior cruciate ligament using autografts is a common procedure performed in the modern era. The peroneus longus tendon is an upcoming graft with several advantages over traditional autografts. It has minimal donor site morbidity in relation to biomechanical properties of the ankle. Common peroneal nerve injury during harvest is a theoretical concern while harvesting the peroneus longus tendon. The following case highlights the importance of careful surgical technique and timely intervention while dealing with such complications. A 25-year-old male suffered an anterior cruciate ligament rupture while wrestling. He had an unstable knee and difficulty performing daily activities. He underwent an arthroscopic anterior cruciate ligament reconstruction using peroneus longus tendon autograft. Following surgery, the patient reported a foot drop and decreased sensations over the dorsum of the foot. The patient was advised of a foot drop splint and neuroprotective medications. Neurophysiological studies were not performed since they cannot differentiate between partial and complete nerve injury in the first week after injury. A surgical exploration of the nerve was done. An intraneural hematoma was found with contusions over the peroneus longus tendon. Neurolysis was performed to decompress the nerve. The functioning of the anterior cruciate ligament was satisfactory during follow-up. An advancing Tinel's sign was noted on follow-up. The patient finally recovered after a 3-month follow-up.