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Insufficient evidence to support peroneus longus tendon over other autografts for primary anterior cruciate ligament reconstruction: a systematic review
  1. Theodorakys Marín Fermín1,2,
  2. Jean Michel Hovsepian3,
  3. Panagiotis D Symeonidis4,
  4. Ioannis Terzidis2,4,
  5. Emmanouil Theodorus Papakostas2,5
  1. 1Orthopedics, Hospital Periferico de Coche, Caracas, Capital District, Venezuela, Bolivarian Republic of
  2. 2Sports Medicine Orthopaedics, TheMIS Orthopaedic Center, Thessaloniki, Central Macedonia, Greece
  3. 3Department of Orthopaedic Sports Medicine, Chirurgisches Klinikum München Süd, München, Bayern, Germany
  4. 4St. Luke’s Hospital, Thessaloniki, Central Macedonia, Greece
  5. 5Sports Medicine Orthopaedics, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Ad Dawhah, Qatar
  1. Correspondence to Dr Theodorakys Marín Fermín, Orthopedics, Hospital Periferico de Coche, Caracas 1090, Capital District, Venezuela, Bolivarian Republic of; theodorakysmarin{at}


Importance Graft choice for anterior cruciate ligament reconstruction (ACLR) remains a subject of interest among orthopaedic surgeons because no ideal graft has yet been found. Peroneus longus tendon (PLT) has emerged as an alternative autograft for reconstruction in kneeling populations and in simultaneous anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries.

Objective To evaluate the current evidence on the outcome of primary ACLR with PLT autograft in adults and donor ankle morbidity, in addition to determining the average PLT graft dimensions from published studies.

Evidence review Two independent reviewers searched PubMed, CENTRAL, EMBASE, Scopus and Virtual Health Library databases using the terms “anterior cruciate ligament,” “peroneus longus” and “fibularis longus” alone and in combination with Boolean operators AND/OR. Studies evaluating clinical and stability outcomes, graft-donor ankle morbidity and graft dimensions of PLT in ACLR were included. Methodological quality was assessed using the Modified Coleman Methodology Score (mCMS). A narrative analysis is presented using frequency-weighted means wherever feasible. Publication bias was assessed using the ROBIS tool.

Findings Twelve articles with intermediate-level methodological quality were included. Eight studies assessing the clinical and stability outcomes of reconstruction with PLT showed satisfactory outcomes, similar to those of hamstring tendons (HT). No studies assessed anterior knee pain as an outcome. Six studies evaluated the graft-donor ankle morbidity using general functional foot and ankle scores and non-validated tools, showing favourable outcomes. Nine studies assessed PLT graft diameter, revealing grafts consistently larger than 7 mm among the different preparation techniques, which is comparable with reports of HT grafts.

Conclusions and relevance The clinical and stability outcomes of ACLR with different PLT autograft preparation techniques are comparable with those of HT during short-term follow-up; however, there is insufficient evidence to support its use in the populations that motivated its implementation. Thus, stronger evidence obtained with the use of validated tools reporting negligible donor-graft ankle morbidity after PLT harvesting is required prior to recommending its routine use, despite the consistency of its dimensions.

Level of evidence Level III.

  • anterior cruciate ligament
  • autografts
  • reconstructive surgical procedures
  • knee
  • arthroscopy

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  • Twitter @anatheomia, @MichelHovsepian

  • Contributors TMF: study design, search, screening process, assessment of study quality, data collection, narrative analysis and manuscript elaboration. Guarantor of the review. JMH: search, screening process, assessment of study quality, data collection, narrative analysis and editing. PDS: narrative analysis, key expert input, critical revision. IT and ETP: key expert input, critical revision and assessment of publication bias. All authors read and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as online supplemental information. Statistical information regarding the systematic review and any other required additional information will be available on request.

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