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Abstract

Background:

Anterior cruciate ligament reconstruction (ACLR) is a common orthopaedic procedure for which various graft options can be used. This systematic review and meta-analysis aimed to compare the efficacy of the peroneus longus tendon (PLT) and hamstring tendon (HT) autografts for primary ACLR.

Hypothesis:

There would be no significant difference in patient outcomes between PLT and HT autografts in ACLR.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

Adhering to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a thorough literature search was conducted on February 10, 2024, across the PubMed, Cochrane CENTRAL, and Scopus databases. The aim was to identify comparative studies investigating the effectiveness of PLT and HT autografts for primary ACLR. The initial literature search retrieved 96 studies. Ten studies met the eligibility criteria for inclusion. Data analysis was performed using RevMan Version 5.4.1. Functional scores, graft characteristics, donor site morbidity, and failure rates were compared.

Results:

Ten studies involving 949 patients were included. Both the PLT and HT groups showed comparable functional outcomes, knee stability, and graft failure rates. PLT autografts demonstrated a larger mean graft diameter (8.63 mm vs 8.08 mm) and lower incidence of donor site morbidity (7.48% vs 22.01%) than HT autografts. There was a statistically significant mean difference (MD) favoring PLT autografts in the modified Cincinnati score (MD, 3.33; 95% CI, 1.84 to 4.81; P < .0001) and thigh circumference (MD, –7.62 mm; 95% CI, –8.90 to −6.33; P < .00001).

Conclusion:

This review showed that both PLT and HT autografts are effective options for primary ACLR, with similar functional outcomes and knee stability. PLT autografts offer advantages in terms of graft diameter and donor site morbidity. Further research is warranted to confirm these findings and guide clinical decision-making in ACLR practice.

Keywords

anterior cruciate ligament reconstruction peroneus longus tendon hamstring tendon systematic review meta-analysis

The anterior cruciate ligament (ACL) assumes a pivotal role in maintaining knee joint stability by preventing excessive anterior translation and internal rotation of the tibia relative to the femur.²⁶ ACL injuries are among the most common types of knee injuries and can result in anterior or anterolateral knee instability. These injuries may affect people of varying ages and levels of physical activity.^{2,10,15,16,43} This can occur as a result of sports-related noncontact injuries, mainly cutting, pivoting, and jumping activities or other contact injuries.^5,12,23

Surgical intervention stands as the cornerstone for achieving optimal outcomes after ACL injury.³⁹ The ACL reconstruction (ACLR) procedure improves the stability of the knee and decreases the possibility of subsequent problems, such as meniscal tears and osteoarthritis.^6,25,31,35 Among the array of autograft options,^28,29,41 including bone–patellar tendon–bone (BPTB), hamstring, and quadriceps tendon grafts, no definitive gold standard exists due to inherent drawbacks associated with each choice. While BPTB grafts are favored among athletes seeking an expedited return to sports, they are frequently linked to kneeling pain. Conversely, hamstring tendon (HT) grafts, currently a popular choice, exhibit elevated rates of graft failure and laxity compared with BPTB grafts.⁴⁸ It is important to note that the majority of autografts that are used are harvested from the region surrounding the knee joint, thereby predisposing patients to potential complications such as knee laxity or imbalances between the hamstring and quadriceps musculature postharvesting. An ideal graft choice for ACLR would be a graft with biomechanical properties, strength, and cross-sectional area similar to native ACL and minimal or no morbidity around the knee joint. Recently, peroneus longus tendon (PLT) autograft has been increasingly used for ACLR, both primary and revision. The PLT's accessibility and sufficient length for ACLR, as described by Butt et al,¹¹ allow for a straightforward harvesting technique that preserves ankle function. Exhibiting biomechanical properties comparable to those of the native ACL, PLT presents an enticing alternative owing to its negligible morbidity at the knee joint.^17,32

PLT and HT autografts have been compared from the perspective of primary ACLR in a number of studies; nevertheless, the results have been conflicting. In light of this, it is necessary to do a thorough analysis of the literature that is currently available in order to provide direction for clinical practice and surgical decision-making.

PLT and HT autografts for ACLR have been the subject of 4 systematic reviews,^19,27,30,47 which concluded that there is no substantial difference between PLT and HT autografts. The dynamic nature of research in this field demands an updated meta-analysis. The purpose of this study was to undertake a comprehensive review and meta-analysis of comparative studies of PLT and HT autografts in primary ACLR. We hypothesized that there would be no difference in patient-reported outcomes between the use of HT and PLT graft types use for ACLR.

Methods

This systematic review was done according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines,²⁴ and the study protocol, which outlines the research methodology and objectives, was officially registered in PROSPERO, a database for systematic reviews, under the unique identification code CRD42024517199. We structured our approach based on the population, intervention, control, and outcomes framework detailed in Appendix Table A1 (available in the online version of this article).

Types of Studies

Two independent reviewers (K.K. and V.R.) systematically reviewed all comparative studies, encompassing randomized controlled trials (RCTs), observational studies, and longitudinal studies, that specifically compared the clinical outcomes of ACLR utilizing either PLT or HT autografts.

Search Strategy

A comprehensive search was conducted across English-language publications in the PubMed, Cochrane CENTRAL, and Scopus databases. The objective was to identify clinical studies comparing the effectiveness of PLT autograft with HT autograft in primary ACLR. This exhaustive search included all relevant studies published until February 10, 2024. We conducted a systematic search for all RCTs, observational studies, and longitudinal studies that compared the use of PLT and HT autografts in ACLR. Appendix Table A2 (available online) provides detailed information on the search strategy and methodology. We excluded case reports, case series, cadaveric studies, biomechanical studies, and review articles from our analysis. The inclusion criteria consisted of patients with an ACLR with a PLT or HT autograft, a primary ACLR, and age ≥15 years. The exclusion criteria were patients with a revision ACLR, a previous knee surgery, a contralateral knee injury, ca hronic degenerative disease, a primary ACLR with allograft, and multiple ligamentous knee reconstructions.

Study Selection

After the database searches, 2 independent authors (K.K. and V.R.) evaluated the titles and abstracts of the initial searches to identify relevant studies according to the inclusion and exclusion criteria. The resolution of any discrepancies or disagreements was done through discussions between both authors, with the assistance of a third author (A.K.P.) if consensus could not be achieved. The primary outcomes of this review were the Lysholm score, International Knee Documentation Committee (IKDC) score, and modified Cincinnati score. The secondary outcomes were the anterior drawer test (grade 0 or 1), pivot-shift test (grade 0 or 1), Lachman test (grade 0 or 1), graft diameter, donor site complications (infection, paresthesia, and/or pain), American Orthopaedic Foot & Ankle Society (AOFAS) score/Foot and Ankle Disability Index (FADI) score, and graft failure.

Data Extraction

After the identification of all studies that were considered eligible for inclusion, an electronic data extraction spreadsheet was created to capture all pertinent study data. Any disagreement in the cited eligible studies was resolved by a third reviewer (A.K.P.). In cases necessitating additional information or clarification, authors were contacted via email. Independent extraction of the following data was done by both authors (K.K. and V.R.): first author's name, year of publication, country, journal name, study type (RCT, observational, or longitudinal study), total sample size, number of patients in the PLT group, number of patients in the HT group, baseline data, and primary and secondary outcomes.

Assessment of Risk of Bias

The Cochrane tool²¹ was utilized to assess the risk of bias in RCTs, considering factors such as selection, performance, attrition, reporting, detection bias, and other potential sources of bias. The risk of bias evaluation in all nonrandomized observational studies was conducted using the Newcastle-Ottawa Scale (NOS),⁷ which evaluates group selection, group comparability, and ascertainment of the outcome of interest. A rating of 8/9 stars denoted a low risk of bias, 7 stars signified a moderate risk, and <6 stars indicated a high risk. Any discrepancies were resolved through discussion among the 2 independent authors, with involvement of a third author, if needed.

Data Synthesis

Review Manager³³ (RevMan) software for Windows (Version 5.4.1; Cochrane Collaboration) was utilized for data synthesis. Summary measures for dichotomous variables, representing results with 2 possible outcomes, were calculated using odds ratios (ORs) and risk differences. For continuous variables, which represent measurements along a continuum, mean differences (MDs) were utilized. To assess the degree of variation among studies, heterogeneity was evaluated using the Cochran Q test, a statistical method that examines differences beyond what would be expected by chance. Specifically, I² values >50% were considered indicative of substantial heterogeneity, suggesting diverse results among the studies analyzed. When significant heterogeneity was observed, random-effects modeling was used. A P value <.05 was deemed statistically significant.

Results

Results of Literature Search

In the initial literature search, 96 studies were retrieved. After removing duplicates, the articles underwent screening based on predefined inclusion and exclusion criteria. Subsequently, 15 articles^‡ were selected for full-text review. After this thorough evaluation, 10 studies^§ met the criteria for quantitative analysis. The process is visually depicted in a PRISMA flowchart (Figure 1).

Figure 1.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart. ACL, anterior cruciate ligament; MCL, medial collateral ligament; PLT, peroneus longus tendon.

Study and Patient Characteristics

Ten studies^‖ (4 with level of evidence 1, 4 with level of evidence 2, and 2 with level of evidence 3) compared 467 patients with PLT to 482 patients with HT, with a mean follow-up time of 19.5 months. The mean age of the participants was 28.66 years, with males representing 76.92% of the total population. Detailed information regarding study characteristics is presented in Table 1, while Table 2 provides an overview of patient characteristics.

Table 1

Study Characteristics ^a

First Author	Year	Country	Journal	Study Type	Total Sample Size	LOE
Acharya¹	2024	India	The Archives of Bone and Joint Surgery	Retrospective cohort	60	3
Agarwal³	2023	India	Cureus	Prospective cohort	194	2
Bi⁸	2018	China	The Journal of Knee Surgery	RCT	124	1
Gunadham¹⁸	2022	Thailand	Journal of Orthopaedics	Retrospective cohort	52	3
Hegde²⁰	2023	India	Muscle, Ligaments and Tendons Journal	Prospective cohort	54	2
Keyhani²²	2022	Iran	The Archives of Bone and Joint Surgery	Prospective cohort	130	2
Rhatomy³⁴	2019	Indonesia	Knee Surgery, Sports Traumatology, Arthroscopy	Prospective cohort	52	2
Saeed³⁷	2023	Pakistan	Journal of Bone & Joint Surgery	RCT	158	1
Shair⁴⁰	2022	Pakistan	Rawal Medical Journal	RCT	80	1
Vijay⁴⁶	2022	India	Journal of Orthopaedics, Trauma and Rehabilitation	RCT	45	1

LOE, level of evidence; RCT, randomized controlled trial.

Table 2

Study Demographics ^a

First Author	Year	No. (PLT vs HT)	Mean Age, y (PLT vs HT)	Males (PLT vs HT)	Females (PLT vs HT)	Mean Follow-up,mo
Saeed³⁷	2023	85 vs 73	29.55 ± 6.40 vs 29.55 ± 6.40	138	20	24
Bi⁸	2018	62 vs 62	29.1 ± 6.5 vs 27.9 ± 6.7	34 vs 31	28 vs 31	30.0 ± 3.6
Shair⁴⁰	2022	40 vs 40	25.8 ± 8.6 vs 27.4 ± 9.1	34 vs 32	6 vs 8	9
Vijay⁴⁶	2022	23 vs 22	33.57 ± 9.54 vs 31.82 ± 9.62	17 vs 18	6 vs 4	12
Hegde²⁰	2023	27 vs 27	31.74 ± 7.744 vs 32.11 ± 9.460	20 vs 25	7 vs 2	24
Agarwal³	2023	98 vs 96	28.00 ± 4.91 vs 27.50 ± 4.06	68 vs 57	30 vs 39	12
Keyhani²²	2022	65 vs 65	29.80 ± 7.5 vs 27.60 ± 8.1	58 vs 61	7 vs 4	24
Rhatomy³⁴	2019	13 vs 39	23.4 ± 8.1 vs 26.4 ± 8.6	20 vs 24	4 vs 4	12
Gunadham¹⁸	2022	24 vs 28	27.6 ± 9.4 vs 31.1 ± 10.7	1 vs 38	3 vs 10	36
Acharya¹	2024	30 vs 30	27.73 ± 7.32 vs 28.56 ± 7.52	28 vs 26	2 vs 4	12
Total		467 vs 482	28.66	730	219	19.5

HT, hamstring tendon; PLT, peroneus longus tendon.

Risk of Bias Assessment

In our review, the evaluation of bias risk, as depicted in Figure 2 and summarized in Table 3, revealed that all 6 nonrandomized observational studies received an NOS⁷ score of 8, indicating consistent high quality across the observational studies evaluated. In the assessment of bias risk according to the Cochrane criteria for RCTs,²¹ it was observed that 3 studies within our review did not attain sufficient blinding of both participants and researchers. Additionally, 1 study lacked comprehensive descriptions of its randomization procedure. Despite these limitations, a thorough examination revealed that all included studies exhibited a commendable low risk of bias in terms of management of incomplete outcome data and avoidance of selective outcome reporting.

Figure 2.

Risk of bias assessment (Cochrane criteria for randomized controlled trials).

Table 3

Newcastle-Ottawa Scale Risk of Bias Assessment ^a

First Author	Representativeness	Selection of Nonexposed Cohorts	Ascertainment of Exposure	Demonstration Outcome of Interest Not Present at Start of Study	Comparability	Assessment of Outcome	Long Follow-up (>6 mo)	Adequacy of Follow-up	Total No. of Stars
Rhatomy³⁴	Center based	Same setting (1)	Secure record (1)	Yes (1)	Adjusted (2)	Directly measured (1)	Yes (1)	Yes (1)	8
Keyhani²²	Single center based	Same setting (1)	Secured record (1)	Yes (1)	Adjusted (2)	Directly measured (1)	Yes (1)	Yes (1)	8
Gunadham¹⁸	Center based	Same setting (1)	Secured record (1)	Yes (1)	Adjusted (2)	Directly measured (1)	Yes (1)	Yes (1)	8
Agarwal³	Single center based	Same setting (1)	Secured record (1)	Yes (1)	Adjusted (2)	Directly measured (1)	Yes (1)	Yes (1)	8
Hegde²⁰	Single center based	Same setting (1)	Secured record (1)	Yes (1)	Adjusted (2)	Directly measured (1)	Yes (1)	Yes (1)	8
Acharya¹	Single center based	Same setting (1)	Secured record (1)	Yes (1)	Adjusted (2)	Directly measured (1)	Yes (1)	Yes (1)	8

Data in parentheses are number of stars.

Outcome Synthesis

Primary Outcomes

Patient-Reported Outcome Measures

The Lysholm score was reported in 7 studies,^{1,3,20,34,37,40,46} among which in 327 patients PLT autograft was used and in 316 patients HT autograft was used. The mean Lysholm score was 94.92 with PLT and 94.17 with HT. There was no significant difference observed in the postoperative Lysholm scores (MD, 0.38; 95% CI, –0.43 to 1.20; I² = 56%; P = .36). The statistical heterogeneity for this outcome was substantial, with an I² of 56%, indicating significant diversity among the included studies.

In comparing PLT and HT autografts, no significant difference was found in the IKDC score across 8 studies^{1,3,8,20,22,34,37,40} with a total of 431 reconstructions (MD, 0.51; 95% CI, –0.59 to 1.61; I² = 62%; P = .36).

The modified Cincinnati score was reported in 4 studies,^20,34,40,46 with 114 patients undergoing treatment with PLT and 117 patients with HT. The mean modified Cincinnati score was 89.90 with PLT and 86.4 with HT. There was a statistically significant difference in favor of PLT (MD, 3.33; 95% CI, 1.84-4.81; I² = 0%; P <.0001) (Figure 3).

Figure 3.

Forest plots showing patient-reported outcome measurements comparing hamstring tendon (HT) and peroneus longus tendon (PLT) for anterior cruciate ligament reconstruction. (3.1) Lysholm score forest plot. (3.2) International Knee Documentation Committee score forest plot. (3.3) modified Cincinnati score forest plot.

Secondary Outcomes

Knee Stability

Comparable results were observed between the PLT and HT autograft groups regarding the pivot-shift test (grade 0 or 1) (3 studies^3,8,46; 183 reconstructions; OR, 0.33; 95% CI, 0.03-3.23; I² = 0%; P = .34), anterior drawer test (grade 0 or 1) (4 studies^3,8,18,46; 196 reconstructions; OR, 0.59; 95% CI, 0.18-1.95; I² = 0%; P = .39), and Lachman test (grade 0 or 1) (4 studies^1,3,20,46; 178 reconstructions; OR, 1.03; 95% CI, 0.14-7.45; I² = 0%; P = .97) (Figure 4).

Figure 4.

Forest plots showing knee stability comparing hamstring tendon (HT) and peroneus longus tendon (PLT) for anterior cruciate ligament reconstruction. (4.1) Pivot-shift test. (4.2) Anterior drawer test. (4.3) Lachman test.

Graft Diameter

The mean diameter of the graft was analyzed across 6 studies,^{1,8,18,22,34,37} encompassing 279 cases treated with PLT and 297 cases treated with HT. In the PLT group, the mean graft diameter was reported as 8.63 mm, while in the HT group, it measured 8.08 mm. A statistically significant difference favoring the PLT graft was observed (MD, 0.46; 95% CI, 0.05 to 0.87), along with substantial heterogeneity (I² = 94%; P = .03) (Figure 5).

Figure 5.

Forest plot showing graft diameter comparing hamstring tendon (HT) and peroneus longus tendon (PLT) for anterior cruciate ligament reconstruction.

Graft Failure or ACL Rerupture

Graft failure or ACL rerupture rates were documented in 4 studies,^3,18,22,37 involving 261 patients who received treatment with PLT autograft and 273 patients who underwent treatment with HT autograft. Among the PLT group, 4.2% of patients experienced graft rupture, while a similar proportion (4.3%) was observed among HT patients. Notably, the incidence rates of graft failure and ACL rerupture were comparable between the PLT and HT groups (OR, 0.96; 95% CI, 0.43-2.15). Additionally, there was minimal heterogeneity (I² = 9%; P = .92) (Figure 6).

Figure 6.

Forest plot showing graft failure comparing hamstring tendon and peroneus longus tendon for anterior cruciate ligament reconstruction.

Mean Difference in Thigh Circumference

The mean difference in thigh circumference was examined in 3 studies,^3,22,34 encompassing 187 patients in whom PLT autograft was used and 189 patients in whom HT autograft was used. In the PLT group, the mean difference in thigh circumference was 3.18 mm, while in the HT group, it measured 10.8 mm. The statistically significant mean difference favored PLT (MD, –7.62; 95% CI, –8.90 to −6.33; I² = 64%; P < .00001) (Figure 7).

Figure 7.

Forest plot showing mean difference in thigh circumference comparing hamstring tendon and peroneus longus tendon for anterior cruciate ligament reconstruction.

Donor Site Complications

The donor site morbidity assessment was done in 5 studies,^{1,22,32,37,46} involving 227 patients with PLT and 218 patients with HT. Across the PLT group, 7.48% of the patients experienced donor site morbidity, whereas in the HT group, this figure was 22.01%. However, no statistically significant difference was observed (OR, 0.32; 95% CI, 0.07-1.41; I² = 68%; P = .13) (Figure 8).

Figure 8.

Forest plot showing donor site morbidity comparing hamstring tendon and peroneus longus tendon for anterior cruciate ligament reconstruction.

AOFAS in PLT

The AOFAS score was reported in 8 studies,^{1,3,8,20,34,37,40,46} with 389 patients treated with PLT. Before surgery, the mean AOFAS score was 97.66, slightly decreasing to 96.89 postoperatively. No statistically significant difference was found between the preoperative and postoperative scores, with a mean difference of 0.68 (95% CI, –1.40 to 2.77). However, considerable heterogeneity was observed (I² = 96%; P = .52), as depicted in Figure 9.

Figure 9.

Forest Plot showing American Orthopaedic Foot & Ankle Society score in peroneus longus tendon for anterior cruciate ligament reconstruction.

Discussion

This systematic review and meta-analysis included 10 comparative studies involving 949 patients (467 with PLT, with 482 HT) undergoing primary ACLR. The major findings indicate that functional outcomes, as measured by the Lysholm (MD, 0.38; P = .36) and IKDC (MD, 0.51; P = .36) scores, were comparable between the PLT and HT groups. However, PLT demonstrated a statistically significant advantage in modified Cincinnati scores (MD, 3.33; P < .0001), suggesting superior early functional recovery. PLT also yielded a significantly larger mean difference in graft diameter (MD, 0.46 mm; P = .03) and a smaller mean difference in thigh circumference (MD, –7.62 mm; P < .00001), indicating reduced donor site muscle atrophy. Graft failure rates were nearly identical between PLT (4.2%) and HT (4.3%) (OR, 0.96; P = .92). While donor site morbidity was lower in the PLT group (7.48% vs 22.01%), the difference was not statistically significant (P = .13). These findings suggest that PLT is functionally equivalent to HT and may provide additional advantages in specific clinical domains.

The patient-reported outcome measures (PROMs) analyzed in this review included Lysholm,⁹ modified Cincinnati,⁴ and IKDC⁴⁵ scores. Comparable results were observed across all assessment tools between the PLT and HT autografts, except for the modified Cincinnati score, which showed a statistically significant difference in favor of PLT autografts (MD, 3.33; 95% CI, 1.84-4.81; P < .0001). The modified Cincinnati score is a widely used tool for assessing knee function, specifically focusing on pain, swelling, giving way, and the ability to perform daily and sports activities. The significant improvement in the modified Cincinnati score for PLT autografts highlights their potential advantage in promoting better functional recovery and patient satisfaction. This score is particularly valued for its sensitivity to changes in knee function over time, making it an excellent measure for evaluating recovery trajectories post-ACLR. Despite the similarity in PROMs between PLT and HT autografts, the ability to effectively compare the findings of the reviewed studies could be impacted by several variables. These factors encompass the duration between injury occurrence and surgical intervention, the intricacies of surgical techniques utilized, variations in study methodologies, nuances in postoperative protocols, and the quality of rehabilitation care administered. Considering these diverse elements is essential for accurately interpreting and contextualizing the results across different studies.

Stability assessment is critical after ACLR, with the Lachman test, anterior drawer test, and pivot-shift test being the most widely accepted tools. This review found no statistically significant differences in stability metrics between PLT and HT grafts. The pivot-shift test (OR, 0.33; P = .34), anterior drawer test (OR, 0.59; P = .39), and Lachman test (OR, 1.03; P = .97) each confirmed comparable biomechanical integrity between graft types. This equivalence reinforces the structural reliability of PLT in replicating native ACL mechanics. Additionally, the negligible differences across stability tests suggest that PLT is not only a viable substitute but also functionally noninferior to HT in resisting anterior translation and rotational instability.

The analysis revealed a statistically significant difference in graft diameter among the PLT and HT groups, with the PLT group exhibiting a larger diameter by a mean difference of 0.46 (95% CI, 0.05-0.87; P = .03). The mean graft diameter in the PLT group was 8.63 mm, and in the HT group it was 8.08 mm. This finding underscores the potential structural superiority of PLT autografts to HT counterparts, suggesting that the larger graft diameter in PLT grafts may confer advantages in biomechanical properties and long-term stability. Spragg et al⁴⁴ conducted a comprehensive investigation wherein they observed that with each incremental increase of 0.5 mm in graft ranging from 7.0 to 9.0 mm, there was a notable reduction in the likelihood of patients necessitating revision ACLR. Specifically, for every 0.5-mm augmentation in graft diameter, the probability of requiring revision ACLR decreased by a factor of 0.82. The larger diameter of PLT autografts may result from its anatomic properties, including a thicker tendon structure compared with the semitendinosus and gracilis tendons typically used in HT grafts.⁴² This structural superiority could enhance load-bearing capacity and resist stretching over time, as suggested by Rhatomy et al.³⁴ However, the high heterogeneity in graft diameter measurements may reflect variability in harvesting techniques or measurement methods across studies, necessitating standardized protocols in future research

Although no statistically significant differences were found in overall donor site morbidity rates between the PLT and HT groups, it is noteworthy that PLT autografts exhibited a lower incidence of donor site morbidity than HT autografts. This observation has implications for postoperative recovery and patient satisfaction. Additionally, PLT grafts were associated with a smaller mean difference in thigh circumference compared with HT grafts, suggesting potentially reduced muscle atrophy and functional deficits at the donor site.

HT harvest often disrupts the hamstring-quadriceps balance, potentially compromising dynamic knee stability and increasing injury risk during rehabilitation; in contrast, PLT harvest, occurring distal to the knee, minimizes local morbidity, with the peroneus brevis compensating for its loss in ankle eversion and plantarflexion.¹⁷ This underscores the importance of considering donor site morbidity when selecting graft options for ACLR, as it may influence postoperative rehabilitation and patient satisfaction.

Ankle stability is a theoretical concern with PLT harvesting. The PLT serves as a dynamic stabilizer for the ankle and foot in addition to its primary role in plantarflexion and eversion of the foot.¹⁹ In a physically active patient, it is imperative to determine the impact of PLT harvesting on ankle stability. Our meta-analysis, including data from 10 studies, showed that there were no differences in pre- and postoperative ankle stability using functional score. The mean preoperative AOFAS score was slightly higher than the postoperative score; however, there was no statistically significant difference between the preoperative and postoperative AOFAS scores. This suggests that PLT autografts do not significantly impact functional outcomes, as measured by the AOFAS score, indicating comparable preoperative and postoperative foot and ankle functions in patients undergoing ACLR with PLT grafts. It is essential to recognize that neither the AOFAS score nor the FADI has been validated for assessing PLT morbidity. Marín Fermín et al²⁷ advocated the use of a validated measure, such as the Patient-Reported Outcomes Measurement Information System score, to identify clinically significant differences in donor site morbidity after PLT harvesting for ACLR.

Graft failure in ACLR signifies loss of graft integrity or function, often requiring revision. In this meta-analysis of 949 patients, failure rates were comparable between PLT and HT autografts (4.2% and 4.3%, respectively), consistent with prior comparative studies.^18,19 This similarity, observed over a mean follow-up of 19.5 months, reflects short-term graft reliability in both groups. PLT's slightly larger graft diameter (8.63 mm vs 8.08 mm) and its biomechanical properties akin to the native ACL may contribute to its durability,^18,19 potentially mitigating the increased laxity historically associated with HT autografts.²⁰ However, methodological variability, particularly in graft preparation and surgical technique, along with limited long-term follow-up restricts definitive conclusions.

While PLT was not directly compared with BPTB grafts, its failure profile appears closer to that of BPTB than of HT, which has demonstrated higher failure and laxity rates over time.^20,22 Given the association between graft failure and secondary meniscal injuries, as well as increased osteoarthritis risk,^16,25 sustained stability is critical. Although early results suggest that PLT is a viable alternative to HT, especially in patients with high demand, long-term studies exceeding 5 years are essential to evaluate late graft integrity and clarify whether PLT confers any protective advantage beyond short-term equivalence.

Limitations

Although this meta-analysis provides valuable insights into the comparative outcomes of PLT and HT autografts for ACLR, several limitations should be acknowledged. Despite strict inclusion criteria, heterogeneity remained high in outcomes like graft diameter and donor site morbidity. Differences in surgical techniques, rehabilitation protocols, and outcome assessment tools may influence the pooled results. Furthermore, most included studies had short to intermediate follow-up (12-24 months), limiting assessment of long-term outcomes like osteoarthritis or graft longevity beyond 5 years. Furthermore, the reliance on observational designs in several studies introduces a risk of selection and performance bias, although quality scores were acceptable.

Conclusion

Our review showed that both PLT and HT autografts are effective options for primary ACLR, with similar functional outcomes and knee stability. PLT autografts offer advantages in terms of graft diameter and donor site morbidity. Further research is warranted to confirm these findings and guide clinical decision-making in ACLR practice.

Footnotes

Appendix

Appendix Table A2

Search Strategy

PubMed	(“Anterior Cruciate Ligament”[Mesh] OR “Anterior Cruciate Ligament Reconstruction”[Mesh] OR (“Anterior Cruciate Ligament Reconstruction”[tiab] OR “acl reconstruction”[tiab])) AND (“peroneus longus tendon”[tiab] OR “peroneus longus”[tiab] OR PLT[tiab] OR “fibularis longus”[tiab] OR “peroneus longus graft”[tiab]) AND (“hamstring tendon graft”[tiab] OR “hamstring graft”[tiab] OR “hamstring tendon”[tiab] OR hamstring[tiab] OR semitendinosus[tiab] OR HT[tiab])
Scopus	( INDEXTERMS ( “anterior cruciate ligament” ) OR INDEXTERMS ( “anterior cruciate ligament reconstruction” ) OR ( TITLE-ABS ( “anterior cruciate ligament reconstruction” ) OR TITLE-ABS ( “acl reconstruction” ) ) ) AND ( TITLE-ABS ( “peroneus longus tendon” ) OR TITLE-ABS ( “peroneus longus” ) OR TITLE-ABS ( plt ) OR TITLE-ABS ( “fibularis longus” ) OR TITLE-ABS ( “peroneus longus graft” ) ) AND ( TITLE-ABS ( “hamstring tendon graft” ) OR TITLE-ABS ( “hamstring graft” ) OR TITLE-ABS ( “hamstring tendon” ) OR TITLE-ABS ( hamstring ) OR TITLE-ABS ( semitendinosus ) OR TITLE-ABS ( ht ) )
Cochrane CENTRAL	([mh “Anterior Cruciate Ligament”] OR [mh “Anterior Cruciate Ligament Reconstruction”] OR (“Anterior Cruciate Ligament Reconstruction”:ti,ab OR “acl reconstruction”:ti,ab)) AND (“peroneus longus tendon”:ti,ab OR “peroneus longus”:ti,ab OR PLT:ti,ab OR “fibularis longus”:ti,ab OR “peroneus longus graft”:ti,ab) AND (“hamstring tendon graft”:ti,ab OR “hamstring graft”:ti,ab OR “hamstring tendon”:ti,ab OR hamstring:ti,ab OR semitendinosus:ti,ab OR HT:ti,ab)

Final revision submitted April 10, 2025; accepted May 6, 2025.

The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Ethical approval was not sought for the present study.

‡

References 1, 3, 8, 13, 14, 18, 20, 22, 34, 36 -38, 40, 42, .

§

References 1, 3, 8, 18, 20, 22, 34, 37, 40, .

‖

References 1, 3, 8, 18, 20, 22, 34, 37, 40, .

ORCID iD

Krishan Kumar

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Peroneus Longus Tendon Versus Hamstring Tendon Autograft for Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Comparative Studies

Abstract

Background:

Hypothesis:

Study Design:

Methods:

Results:

Conclusion:

Keywords

Methods

Types of Studies

Search Strategy

Study Selection

Data Extraction

Assessment of Risk of Bias

Data Synthesis

Results

Results of Literature Search

Study and Patient Characteristics

Risk of Bias Assessment

Outcome Synthesis

Primary Outcomes

Patient-Reported Outcome Measures

Secondary Outcomes

Knee Stability

Graft Diameter

Graft Failure or ACL Rerupture

Mean Difference in Thigh Circumference

Donor Site Complications

AOFAS in PLT

Discussion

Limitations

Conclusion

Footnotes

Appendix

‡

§

‖

ORCID iD

References