Insufficient evidence to support peroneus longus tendon over other autografts for primary anterior cruciate ligament reconstruction: a systematic review.
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.
['Marín Fermín|Theodorakys|T|0000-0002-1698-9517', 'Hovsepian|Jean Michel|JM|', 'Symeonidis|Panagiotis D|PD|', 'Terzidis|Ioannis|I|', 'Papakostas|Emmanouil Theodorus|ET|']
D000328:Adult D016118:Anterior Cruciate Ligament D000070598:Anterior Cruciate Ligament Injuries D059549:Anterior Cruciate Ligament Reconstruction D064592:Autografts D006801:Humans D013710:Tendons
autografts anterior cruciate ligament knee arthroscopy reconstructive surgical procedures