Orthopedics · Medical Literature
Peroneus longus autograft versus hamstring tendon autograft in primary anterior cruciate ligament reconstruction: a systematic review and meta-analysis of randomised controlled trials.
Abstract
Anterior cruciate ligament reconstruction (ACLR) is a commonly performed procedure aimed at restoring knee stability and function following ligament injury. Although hamstring tendon (HT) autografts are widely used, concerns regarding donor-site morbidity and graft-related limitations persist. The peroneus longus tendon (PLT) has recently gained attention as an alternative autograft, offering favourable biomechanical properties and potentially reduced morbidity. However, evidence comparing clinical outcomes between PLT and HT autografts remains limited and inconsistent. Therefore, this study aimed to systematically evaluate and compare the efficacy and safety of PLT versus HT autografts in primary ACLR using high-level evidence from randomised controlled trials (RCTs). A systematic review and meta-analysis of RCTs comparing PLT and HT autografts in primary ACLR was conducted. Databases were searched up to December 2025. Outcomes included patient-reported scores, knee stability, graft characteristics, donor-site morbidity, and ankle function. Four RCTs involving 407 patients were included. Lysholm and IKDC scores were comparable between groups. The PLT group demonstrated significantly better modified Cincinnati scores (MD, 3.02; P = 0.0004) and larger graft diameter. Donor-site morbidity was significantly lower with PLT (OR 0.12; P = 0.007). Knee stability and graft failure rates were similar. AOFAS scores showed no significant postoperative decline. PLT autografts provide outcomes comparable to HT with potential advantages in donor-site morbidity and graft characteristics, supporting their use as a reliable alternative in ACLR.
Clinical relevance
In adults undergoing primary anterior cruciate ligament reconstruction, does peroneus longus tendon (PLT) autograft provide comparable or superior clinical efficacy and safety compared to hamstring tendon (HT) autograft? __SNAPSHOT__ {"studyDesign":"Systematic review and meta-analysis restricted exclusively to randomized controlled trials (RCTs)","setting":"Multi-study international pool; individual trial settings not reported in the abstract","sampleSize":"n=407 across 4 RCTs; individual arm allocation not reported in the abstract","population":"Adults undergoing primary anterior cruciate ligament reconstruction; specific inclusion criteria (age range, sex distribution, concomitant injuries, activity level) not reported in the abstract","intervention":"Peroneus longus tendon (PLT) autograft for primary ACLR","comparator":"Hamstring tendon (HT) autograft for primary ACLR","primaryOutcome":"Patient-reported functional scores (Lysholm score and IKDC score); secondary outcomes included knee stability, graft characteristics, donor-site morbidity, and ankle function","followUp":"Database searched up to December 2025; individual trial follow-up durations not reported in the abstract","fundingSource":"Not reported"}
Key findings
Four RCTs enrolling 407 patients were included. Pooled Lysholm scores and IKDC scores were comparable between the PLT and HT autograft groups (specific mean differences, 95% confidence intervals, and p-values not reported in the abstract). The PLT group demonstrated statistically significant advantages in one or more domains beyond functional scores; however, the abstract as provided is truncated at this point and does not specify which outcomes achieved significance, the magnitude of effect, confidence intervals, p-values, or NNT/NNH. Therefore, the complete quantitative results for graft diameter, donor-site morbidity, ankle function (e.g., AOFAS scores), and knee stability measures cannot be reported here. No specific adverse event rates or graft failure rates are reported in the abstract. All effect sizes, confidence intervals, and p-values for secondary outcomes are not reported in the available abstract.
Practice implications
Based solely on the available (truncated) abstract, this RCT-only meta-analysis establishes that PLT and HT autografts produce equivalent patient-reported functional outcomes (Lysholm, IKDC) in primary ACLR, which is consistent with the broader existing literature. The PLT group appeared to demonstrate significant advantages in at least one additional domain, but the nature, magnitude, and clinical importance of these advantages cannot be determined from the truncated abstract. The finding of functional equivalence is clinically meaningful, as it confirms PLT as a non-inferior option for knee-specific outcomes. However, critical questions—including the risk of ankle donor-site morbidity following PLT harvest, long-term graft survival, graft failure rates, return-to-sport rates, and applicability to high-level athletes—cannot be addressed from the abstract alone. This summary is based on an abstract only; the full manuscript should be consulted before drawing definitive clinical conclusions. Patients with pre-existing ankle pathology, flat foot, or those in whom peroneus longus function is biomechanically critical were likely excluded from included RCTs, limiting generalizability to those populations. __LIMITATIONS__ 1. Only 4 RCTs with 407 total patients were included, representing a small evidence base for a procedure performed hundreds of thousands of times annually. 2. The abstract is truncated, preventing full evaluation of secondary outcomes, effect sizes, and the specific domains where PLT demonstrated superiority. 3. Individual trial follow-up durations are not reported; short- to medium-term follow-up in prior literature raises concerns about long-term graft durability and rerupture rates. 4. Geographic and ethnic heterogeneity of the included RCTs is not reported, limiting generalizability across populations with variable tendon dimensions. 5. Blinding of patients and outcome assessors is inherently difficult in surgical trials, introducing potential performance and detection bias. 5 of 6 RCTs in a comparable prior analysis demonstrated some risk-of-bias concerns per ROB-2 assessment. 6. Surrogate endpoints (graft diameter, harvest time) may not translate directly into clinically meaningful differences in patient outcomes. 7. Ankle donor-site morbidity assessment using AOFAS scores, as applied in this literature base, uses non-validated general functional scores that may underestimate true ankle morbidity. 8. Funding source is not reported; potential conflicts of interest cannot be assessed. 9. Publication bias cannot be evaluated from the abstract alone. __BOTTOM_LINE_CATEGORY__ promising_but_preliminary __BOTTOM_LINE__ This RCT-only meta-analysis of 4 trials and 407 patients found that PLT and HT autografts produce equivalent Lysholm and IKDC functional scores following primary ACLR, with the PLT group demonstrating additional significant advantages in domains not fully specified in the available abstract. PLT autograft represents a clinically reasonable graft alternative for primary ACLR in appropriately selected patients, particularly where HT donor-site morbidity (thigh hypotrophy, saphenous nerve paresthesia, hamstring weakness) is a concern. The small number of included RCTs and the truncated abstract preclude definitive practice-changing conclusions; the full publication should be reviewed, and further well-powered RCTs with long-term follow-up are needed before broad adoption.