Comparative Functional Outcomes and Donor-Site Morbidity of Peroneus Longus Versus Hamstring Tendon Autografts in Arthroscopic Anterior Cruciate Ligament Reconstruction
DOI:
https://doi.org/10.52206/jsmc.2026.16.2.1525Abstract
Background: Hamstring tendon (HT) autografts are widely used in anterior cruciate ligament (ACL) reconstruction; however, donor-site morbidity remains a recognized limitation. The peroneus longus tendon (PLT) has emerged as a potential alternative autograft, though comparative clinical data—particularly from resource-limited settings—remain limited.
Objective: To compare functional outcomes, postoperative complications, and donor-site morbidity between PLT and HT autografts in patients undergoing arthroscopic ACL reconstruction.
Methodology: This retrospective cohort study included 34 patients undergoing primary arthroscopic ACL reconstruction between January 2022 and November 2024, with follow-up completed through December 2025. Patients were equally divided into PLT (n = 17) and HT (n = 17) groups. Functional outcomes were assessed at a minimum 12-month follow-up using the International Knee Documentation Committee (IKDC) subjective score and the Lysholm Knee Scoring Scale. Postoperative complications and donor-site morbidity were also evaluated.
Results: The mean IKDC score was 85.53 ± 2.69 in the PLT group and 86.47 ± 2.58 in the HT group (mean difference −0.94; 95% CI −2.77 to 0.89; p = 0.306). The mean Lysholm score was 87.18 ± 2.74 and 87.53 ± 2.58, respectively (mean difference −0.35; 95% CI −2.18 to 1.47; p = 0.702). Postoperative complication rates were comparable between groups (p = 0.419). Donor-site morbidity was significantly higher in the HT group (58.8%) compared to the PLT group (0%) (p < 0.001). No clinically detectable ankle instability or deformity was observed in the PLT group.
Conclusion: PLT autografts demonstrated comparable short- to medium-term functional outcomes to HT autografts, with significantly lower donor-site morbidity. These findings are preliminary and hypothesis-generating. Larger, prospective studies incorporating objective stability measures and validated ankle assessments are required before definitive conclusions can be drawn.
Keywords: ACL Reconstruction, Autograft, Cohort Study, Hamstring Tendon, Peroneus Longus.
References
Sanders TL, Maradit Kremers H, Bryan AJ, Larson DR, Dahm DL, Levy BA, et al. Incidence of anterior cruciate ligament tears and reconstruction: a 21-year population-based study. Am J Sports Med. 2016;44(6):1502-1507. https://doi.org/10.1177/0363546516629944
Webster KE, Feller JA, Leigh WB, Richmond AK. Younger patients are at increased risk for graft rupture and contralateral injury after anterior cruciate ligament reconstruction. Am J Sports Med. 2014;42(3):641-647. https://doi.org/10.1177/0363546513517540
Ferrero S, Louvois M, Barnetche T, Breuil V, Roux C. Impact of anterior cruciate ligament surgery on the development of knee osteoarthritis: a systematic review and meta-analysis comparing non-surgical and surgical treatments. Osteoarthritis Cartilage Open. 2023;5(3):100366. https://doi.org/10.1016/j.ocarto.2023.100366
Fox MA, Engler ID, Zsidai BT, Hughes JD, Musahl V. Anatomic anterior cruciate ligament reconstruction: Freddie Fu's paradigm. J ISAKOS. 2023;8(1):15-22. https://doi.org/10.1016/j.jisako.2022.08.003
Mohtadi NG, Chan DS, Dainty KN, Whelan DB. Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults. Cochrane Database Syst Rev. 2011;(9):CD005960. https://doi.org/10.1002/14651858.CD005960.pub2
Dai W, Leng X, Wang J, Cheng J, Hu X, Ao Y. Quadriceps tendon autograft versus bone-patellar tendon-bone and hamstring tendon autografts for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med. 2022;50(12):3425-3439. https://doi.org/10.1177/03635465211030259
Tiplady A, Love H, Young SW, Frampton CM. Comparative study of ACL reconstruction with hamstring versus patellar tendon graft in young women: a cohort study from the New Zealand ACL Registry. Am J Sports Med. 2023;51(3):627-633. https://doi.org/10.1177/03635465221146299
Opoku M, Abdramane AM, Abdirahman A, Fang M, Li Y, Xiao W. Can peroneus longus tendon autograft become an alternative to hamstring tendon autograft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. J Orthop Surg Res. 2025;20(1):719. https://doi.org/10.1186/s13018-025-06080-9
Malige A, Baghdadi S, Hast MW, Schmidt EC, Shea KG, Ganley TJ. Biomechanical properties of common graft choices for anterior cruciate ligament reconstruction: a systematic review. Clin Biomech. 2022;95:105636. https://doi.org/10.1016/j.clinbiomech.2022.105636
Rajani AM, Shah UA, Mittal AR, Rajani A, Punamiya M, Singhal R. Functional and clinical outcome of anterior cruciate ligament reconstruction with peroneus longus autograft and correlation with MRI after 3 years. J Orthop. 2022;34:215-220. https://doi.org/10.1016/j.jor.2022.08.027
Kusumastuti AH, Rukmoyo T, Rhatomy S, Sakti YM. Anterior cruciate ligament reconstruction with peroneus longus tendon autograft: functional outcome and donor site morbidity. Orthop J Sports Med. 2020;8(5 Suppl 5):2325967120S00084. https://doi.org/10.1177/2325967120S00084
Gök B, Kanar M, Tutak Y. Peroneus longus vs hamstring tendon autografts in ACL reconstruction: a comparative study of 106 patients' outcomes. Med Sci Monit. 2024;30:e945626. https://doi.org/10.12659/MSM.945626
Joshi S, Shetty UC, Salim MD, Meena N, Kumar RS, Rao VKV. Peroneus longus tendon autograft for anterior cruciate ligament reconstruction: a safe and effective alternative in nonathletic patients. Niger J Surg. 2021;27(1):42-47. https://doi.org/10.4103/njs.NJS_22_20
He J, Tang Q, Ernst S, Linde MA, Smolinski P, Wu S, et al. Peroneus longus tendon autograft has functional outcomes comparable to hamstring tendon autograft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2021;29(9):2869-2879. https://doi.org/10.1007/s00167-020-06279-9
Rhatomy S, Kisworo B, Prihargono B, Rasyid FA, Kressoni N. Peroneus longus tendon regeneration after anterior cruciate ligament reconstruction with magnetic resonance imaging evaluation. Open Access Maced J Med Sci. 2020;8(A):916-920. https://doi.org/10.3889/oamjms.2020.5487
Keyhani S, Qoreishi M, Mousavi M, Ronaghi H, Soleymanha M. Peroneus longus tendon autograft versus hamstring tendon autograft in anterior cruciate ligament reconstruction: a comparative study with a mean follow-up of two years. Arch Bone Jt Surg. 2022;10(8):695.
Kumar K, Rao V, Panda AK, Joshi D. Peroneus longus tendon versus hamstring tendon autograft for primary anterior cruciate ligament reconstruction: a systematic review and meta-analysis of comparative studies. Orthop J Sports Med. 2025;13(9):23259671251374313. https://doi.org/10.1177/23259671251374313
Papalia R, Franceschi F, D'Adamio S, Diaz Balzani L, Maffulli N, Denaro V. Hamstring tendon regeneration after harvest for anterior cruciate ligament reconstruction: a systematic review. Arthroscopy. 2015;31(6):1169-1183. https://doi.org/10.1016/j.arthro.2014.11.015
Konrath JM, Vertullo CJ, Kennedy BA, Bush HS, Barrett RS, Lloyd DG. Morphologic characteristics and strength of the hamstring muscles remain altered at 2 years after use of a hamstring tendon graft in anterior cruciate ligament reconstruction. Am J Sports Med. 2016;44(10):2589-2598. https://doi.org/10.1177/0363546516651441
Islam N, Ferdous GS, Dey D, Rahman M, Diba AN, Rasul A. Peroneus longus tendon autograft in ACL reconstruction—clinical and biomechanical outcomes. Insight. 2025;8(3):514-518.
de Oliveira DE, Horita MM, de Oliveira e Silva M, Salas VER, Jorge PB. Anterior half of the peroneus longus tendon combined with semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction: an athlete case report. Case Rep Orthop. 2021;2021:9978383. https://doi.org/10.1155/2021/9978383
Singh MP, Verma M, Agrawal DR, Gaur TNS, Maravi DS, Dhanopeya A. Evaluation of ankle complications after peroneus longus tendon harvesting for ACL reconstruction. J Orthop Case Rep. 2025;15(6):207-212. https://doi.org/10.13107/jocr.2025.v15.i06.5718
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