A Comparative Study of Functional Outcomes Following Arthroscopic Anterior Cruciate Ligament Reconstruction Using Hamstring Tendon versus Peroneus Longus Tendon Autograft

Introduction

The knee joint is one of the most frequently injured joints in the human body, with the anterior cruciate ligament (ACL) being the most commonly injured ligament requiring surgical intervention ^[1]. The ACL plays a key role in maintaining knee stability by preventing anterior tibial translation and controlling rotational and valgus stresses ^[1,2,3].

ACL injuries are commonly associated with sports activities, road traffic accidents, and non-contact twisting mechanisms. Untreated ACL deficiency results in recurrent instability, secondary meniscal injury, chondral damage, and early-onset osteoarthritis ^[4,5]. Arthroscopic ACL reconstruction has evolved as the gold standard treatment, offering anatomical restoration, minimal invasiveness, faster rehabilitation, and improved functional outcomes ^[6,7].

Various graft options have been described for ACL reconstruction, including bone–patellar tendon–bone, hamstring tendon, quadriceps tendon, and allografts ^[7]. Although bone–patellar tendon–bone graft was once considered the gold standard, complications such as anterior knee pain, patellar fracture, and extensor mechanism dysfunction have limited its use ^[8].

Hamstring tendon autografts have gained popularity due to reduced donor site morbidity and satisfactory functional outcomes ^[9]. Recently, the peroneus longus tendon has been explored as an alternative autograft owing to its adequate length, comparable tensile strength, and minimal functional deficit at the donor site ^[10,11,12]. Biomechanical studies have shown no significant difference in tensile strength between hamstring and peroneus longus tendons ^[13].

This study aims to compare the functional outcomes and donor site morbidity of hamstring tendon and peroneus longus tendon autografts used in arthroscopic ACL reconstruction.

Materials and Methods

Results

A total of 40 patients who underwent arthroscopic ACL reconstruction were included in the study, with 20 patients in each group. Group A underwent reconstruction using hamstring tendon autograft, while Group B underwent reconstruction using peroneus longus tendon autograft.

Discussion

ACL reconstruction aims to restore knee stability, prevent secondary intra-articular damage, and enable patients to return to pre-injury activity levels. The choice of graft plays a critical role in determining post-operative outcomes and donor site morbidity.

In the present study, both hamstring tendon and peroneus longus tendon autografts demonstrated significant improvement in knee function following arthroscopic ACL reconstruction. At final follow-up, there was no statistically significant difference between the two groups in terms of IKDC and Tegner Lysholm scores, indicating that peroneus longus tendon autograft provides functional outcomes comparable to the traditionally used hamstring tendon autograft.

These findings are consistent with previous studies that reported satisfactory clinical outcomes with hamstring tendon autografts due to their adequate strength, ease of harvest, and reduced anterior knee pain when compared to bone–patellar tendon–bone grafts ^[9].

The increasing interest in peroneus longus tendon as an autograft is supported by biomechanical and clinical studies. Rudy et al. demonstrated that the tensile strength of the peroneus longus tendon is comparable to that of the hamstring tendon, making it a suitable graft choice for ACL reconstruction ^[13]. Similarly, Rhatomy et al. reported no significant difference in functional outcomes between peroneus longus and hamstring tendon grafts ^[11].

In the present study, early post-operative IKDC scores at 6 weeks were marginally better in the peroneus longus group. This may be attributed to preservation of hamstring muscle strength, which plays a crucial role in knee flexion and dynamic stabilization of the knee joint. Harvesting hamstring tendons has been associated with transient hamstring weakness, which can delay early rehabilitation ^[13,14].

Donor site morbidity is a major concern when introducing alternative graft options. In our study, donor site morbidity following peroneus longus tendon harvest was minimal and temporary, as evidenced by FADI scores returning to baseline by 6 months. This observation supports the findings of Angthong et al. and Xu et al., who reported preserved ankle function due to the compensatory action of the peroneus brevis muscle, which is the primary evertor of the ankle ^[12,15].

No long-term ankle instability, gait abnormalities, or functional limitations were observed in patients who underwent peroneus longus tendon harvest. This supports the anatomical and functional rationale that the peroneus brevis adequately compensates for the loss of the peroneus longus tendon.

The absence of significant differences in final functional outcomes between the two grafts suggests that peroneus longus tendon autograft can be considered a reliable alternative, particularly in cases where hamstring tendons are inadequate, previously harvested, or need to be preserved.

Conclusion

Peroneus longus tendon autograft is a safe, effective, and reliable alternative to hamstring tendon autograft for arthroscopic ACL reconstruction. It provides comparable functional outcomes with minimal donor site morbidity and can be considered especially in cases where hamstring tendons are inadequate or previously harvested.

Clinical Message

For patients requiring ACL reconstruction, the peroneus longus tendon represents a better alternative to the hamstring graft in terms of graft properties, harvesting time, donor site morbidities, and using a single tendon instead of two hamstring tendons.

References

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About the Authors

• 

  A Manikkumaran

• 

  A Manikandan

• 

  B Vaishnav Kumar