Posterior Cruciate Ligament reconstruction with peroneus longus tendon graft: 2-Years follow-up

Peroneus longus tendon autograft versus allograft in revision ACLR: A retrospective comparison

PURPOSE

The use of peroneus longus tendon (PLT) autografts in primary anterior cruciate ligament reconstruction (ACLR) has increased recently, but there is a lack of research on its use in revision ACLR. This study aimed to compare the clinical outcomes and complications between revision ACLR using allografts and PLT autografts.

MATERIALS AND METHODS

Fifty-nine patients who underwent arthroscopic revision of ACLR with complete clinical follow-ups between 2012 and 2021 were retrospectively reviewed. Allograft was used in 44 of these patients, and PLT autograft was used in 15 of them. Lysholm knee score, Tegner activity score, Lachman, and anterior drawer tests were performed after a mean follow-up of 60months (range: 19-116). The American Orthopaedic Foot and Ankle Society (AOFAS) scale was used to evaluate the donor ankle functions. Clinical outcomes and complications were compared between groups.

RESULTS

Both groups showed significantly improved functional outcomes compared to their preoperative assessments. However, both groups had similar clinical results at the final follow-up, including Lysholm knee score, Tegner activity scale, knee range of motion, return to sports, time to return to daily activities, and rate of re-rupture. No major complications were seen in any of the patients. The AOFAS score was 99.13±2.64 in the PLT autograft group without loss of ankle muscle strength, deformity, instability, and permanent iatrogenic neurovascular injuries. The cumulative cost of the allograft group was significantly higher than the PLT autograft group.

CONCLUSIONS

The PLT autograft might be an alternative autograft option to allografts due to similar clinical outcomes, low donor site morbidity, and reduced cost in ACLR revisions, especially if the primary ACLR was performed using grafts harvested around the knee.

LEVEL OF EVIDENCE

III; retrospective comparative study.

There is a Minimal Difference in Ankle Functional Outcomes After Peroneus Longus Harvest: Systematic Review and Meta-analysis

Importance

Recently, peroneus longus (PL) autograft as a graft choice for ligament surgeries have attracted interest due to studies showing good clinical outcomes and minimal donor site morbidity. There remain concerns related to these grafts, especially the potential impact on ankle functions.

Aims/Objective

The purpose of this review and meta-analysis is to summarize the available evidence for ankle functional outcomes after PL harvest. This will provide objective clinical evidence for surgical decision making.

Evidence Review

Cochrane, Embase, Medline, and Google Scholar were all searched for articles published between January 2001 and May 2021. For the aim of a systematic review, certain inclusion and exclusion criteria were adopted in accordance with PRISMA recommendations. The primary outcome measure was the assessment of ankle functional outcomes using validated instruments (such as AOFAS score, FADI score etc.).

Findings

A total of twelve studies representing pooled patient populations of 537 patients were included in this review. The average follow-up duration was 17 months (range; 6-32 months) across all studies. All twelve studies assessed AOFAS score and six studies also additionally assessed FADI score. The pooled mean outcomes measured showed a slight decrease in post-operative as compared to pre-operative AOFAS and FADI score (mean difference of AOFAS 1.92, 95% CI 1.021-3.123, p value < 0.05 and mean difference for FADI 1.50, 95% CI 0.561-2.445, p value < 0.05). Though statistically significant the magnitude of variance implies minimal clinical impact.

Conclusion and Relevance

This review and meta-analysis found that PL autograft harvest leads to statistically significant but minimal impact on ankle functional outcomes. This, in conjunction with various studies on ankle parameters after PL harvest, shows that PL harvest leads to minimal impact on ankle outcomes and function.

Level of Evidence

Systematic review Level III.

Complications of peroneus longus tendon harvesting: a retrospective review of 82 cases

OBJECTIVE

Peroneus longus tendon (PLT) has become a reliable autologous graft option for various ligament reconstructions. But there are potential risks and complications associated with its use as a graft. This retrospective study aimed to examine the complications and donor site morbidity following PLT harvesting.

PATIENTS AND METHODS

A retrospective review was performed on an institutional digital patient database, and all patients who underwent ligament reconstruction using PLT autograft were identified. Intraoperative, early, and late complications were reviewed using digital patient notes and patients underwent a complete physical examination during their final follow-up. Ankle function was assessed using the AOFAS score, and manual ankle muscle testing was performed on both sides. Sural nerve iatrogenic injury was evaluated with a dermatomal light touch examination. Cosmetic satisfaction due to incision scar and footwear complaints were also assessed.

RESULTS

82 patients (74 male, eight female) with a mean age of 31.9 ± 10.4 years (range, 16-66) were included in the final analysis. The mean follow-up time was 46.6 ± 30.3 months (range, 6-109). The mean AOFAS score for the donor side was 98.7 ± 3.3 (range, 87-100), and the contralateral side score was 100, with manual muscle testing graded as 5 in all movements and similar to the contralateral side. Fifteen patients (18.3%) had hypoesthesia over the dorsolateral aspect of the foot distal to the incision scar, two patients (2.4%) had hyperalgesia over the distal incision scar, and one patient (1.2%) had mild ankle instability. There were two cases (2.4%) of compartment syndrome, both of which were treated with fasciotomy and had complete regression of symptoms after 5 days. One patient (1.2%) had a transient peroneal nerve injury and foot drop that resolved in the sixth month.

CONCLUSIONS

The results of this retrospective study suggest that harvesting the PLT is associated with a high rate of complications and donor site morbidity. The most common complication was hypoesthesia around the lateral side of the foot, although the ankle functions were not affected significantly. Two cases of compartment syndrome and one transient peroneal nerve injury were observed. Care should be taken while harvesting PLT autograft, and it should be kept in mind that peroneal nerve injury might occur.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Peroneus Longus Graft Harvest: A Technique Note

Multiple graft options are available for knee ligament surgeries, one of the latest being peroneus longus grafts. Despite, an increasing usage of PL for graft harvest there is a scarcity of technique guides for its harvest, finding mention in only a few case studies. The following is a technical note dedicated to peroneous longus graft harvest.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-00847-0.

Full-thickness peroneus longus tendon autograft for anterior cruciate reconstruction in multi-ligament injury and revision cases: outcomes and donor site morbidity

PURPOSE

Peroneus longus tendon (PLT) autograft has been successfully used for isolated anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) reconstruction cases. Being a powerful evertor and flexor of great toe, there might be associated ankle morbidity with this autograft option. However, there are only a few studies exploring whether the ankle morbidity is significant or not. This study aims to assess the functional outcomes, donor site morbidity, and ankle strength after harvesting ipsilateral peroneus longus autograft for ACL reconstruction in revision ACL and multi-ligament injury cases.

METHODS

This was a prospective case series. All of the patients were evaluated by clinical examination for knee for laxity, ankle joint stability, and using visual analog scale (VAS) for pain, International Knee Documentation Committee (IKDC) score, and Lysholm score, preoperatively and postoperatively at two-year follow-up. Morbidity of donor ankle was assessed using American Orthopedic Foot and Ankle Society (AOFAS) score, bilateral evertors, and first ray plantarflexion strength measurement using an isometer (Innovative Design Orthopedics) at two-year follow-up.

RESULTS

Ipsilateral PLT graft was used in ten patients of revision ACL reconstruction and 27 patients of the multi-ligament knee injury. The mean length of PLT harvested (cm) was 26.2 (standard deviation 2.6, range 22-31), and mean diameter of the doubled graft (mm) was 7.9 (standard deviation 0.68, range 7.5-8.5). There was a significant improvement in VAS score for pain, Lysholm, and IKDC scores (p =  < 0.001) at two -year follow-up. There were no cases of graft failure, superficial, or deep infection. Ankle dorsiflexion(p = 0.32), ankle plantarflexion (p = 0.19), eversion strength(p = 0.6), first ray plantarflexion strength(p = 0.52), and AOFAS score(p = 0.29) were found to be comparable to the normal side in all patients.

CONCLUSIONS

Peroneus longus autograft can be considered as a potential autograft option for ACL reconstruction in multi-ligament knee injuries and revision ACL reconstruction. No significant donor site morbidity was noted at follow-up.

LEVEL OF EVIDENCE

Level IV.

Stability of the knee after posterior cruciate ligament reconstruction using peroneus longus tendon graft with three femoral insertion sites. A cadaveric study

Introduction

Many kinds of grafts were used for single-bundle reconstruction of the posterior cruciate ligament (PCL). Recently, the peroneus longus tendon (PLT) was used in some clinical reports. This study aimed to test the best position of the femoral insertion in the case of using PLT for PCL reconstruction.

Methods

Seventeen fresh frozen cadaveric knees were randomized into three groups. Group AL (6 knees): the femoral insertion in PCL reconstruction was at the footprint center of the anterolateral bundle (ALB). Group PM (5 knees): at the footprint center of the posteromedial bundle (PMB). And group MC (6 knees) was at the midpoint of the center of the anterolateral bundle and posteromedial bundle. The PCL of all knees was cut and a PCL reconstruction procedure was performed with autologous peroneus longus tendon (PLT). The stability of each knee was tested in three conditions: PCL was intact, PCL was resected, and PCL was reconstructed. The KT-1000 machine was used to measure the maximum posterior displacement of the tibia under force with the knees at 0, 30, 60, 90, and 120 degrees of flexion.

Results

Average posterior displacement of the tibia under force for intact PCL of group AL was 1.6 mm, group MC was 1.2 mm, and group PM was 1.3 mm. After PCL was resected, the knee laxity was increased remarkably: posterior displacement of the tibia of group AL was 8.9 mm, group MC was 9.4 mm, and group PM was 13.6 mm. After PCL was reconstructed, group AL was 1.5 mm, group MC was 2.0 mm, and group PM was 5.6 mm. The results showed that after PCL reconstruction the group AL and group MC give better stability to the knee (p < 0.05, except knee at 120 degrees of flexion). Group AL got more stability than group MC, but the difference was not significant (p ≥ 0.164).

Conclusion

In a single-bundle reconstruction of the PCL with the graft PLT, the femoral insertion at the footprint center of the ALB and the midpoint of the center of the ALB and PMB showed better stability than that at PMB.

The promotive effect of grafts with the double-stranded peroneus longus tendon and with the four-stranded hamstring tendon on reconstruction of the posterior cruciate ligament injury

INTRODUCTION

Posterior cruciate ligament (PCL) injury hampers the rotational stability and stability front to back of the knee joint, seriously affecting the quality of life of patients. Some studies have reported that the peroneus longus tendon (PLT) has sufficient length and strength.

HYPOTHESIS

We hypothesized that the PLT can be used as a novel appropriate material for PCL reconstruction therapy.

MATERIALS AND METHODS

Herein, we systematically analysed the clinical effect of the double-stranded PLT and the four-stranded hamstring tendon in the reconstruction of the PCL and compared the effectiveness and safety of these two surgical approaches in the reconstruction of PCL injury. A total of 48 patients with complete rupture of the PCL were divided into Group A (reconstructed with the double-stranded PLT, 25 cases) and Group B (reconstructed with the four-stranded hamstring tendon, 23 cases).

RESULTS

The patients were followed up for more than 1 year. The intraoperative time for tendon extraction was significantly shorter in Group A than Group B. Twenty-four months after operation, patients in the two groups showed the alleviated tibial posterior displacement and the increased IKDC score, Lysholm score and Tegner score. Nevertheless, these scores showed no significant differences between the two groups. Additionally, compared with the therapy using the four-stranded hamstring tendon, therapy using the double-stranded PLT is simpler and safer.

DISCUSSION

Both surgical methods are effective in the treatment of PCL injury. The PLT could be a good choice for PCL injury reconstruction material, especially when the four-stranded hamstring tendon is accidentally damaged or ineffective. Our study may provide guidance for the clinical treatment of PCL injury.

LEVEL OF EVIDENCE

III, retrospective study.

Allografts as alternative to autografts in primary posterior cruciate ligament reconstruction: a systematic review and meta-analysis

PURPOSE

Following posterior cruciate ligament (PCL) rupture, autografts and allografts are routinely used for its reconstruction. This study investigated the efficacy and safety of allografts for primary PCL reconstruction, comparing them to autografts in terms of patient-reported outcome measures (PROMs), functional tests, and complications.

METHODS

This study followed the PRISMA guidelines. PubMed, Web of Science, Google Scholar, Embase, and Scopus were accessed in October 2022. All the clinical studies investigating the outcomes of primary PCL reconstruction using allografts, or comparing the outcomes of allografts versus autografts, were accessed. The outcomes of interests were: instrumental laxity, range of motion (ROM), Telos stress radiography, drawer test, International Knee Documentation Committee (IKDC), Tegner Activity Scale, and the Lysholm Knee Scoring Scale. Data on complications were also recorded.

RESULTS

A total of 445 patients were included. The mean follow-up was 45.2 ± 23.8 months. The mean age of the patients was 30.6 ± 2.2 years. The time span between the injury and surgical intervention was 12.9 ± 10 months. Overall, 28% (125 of 445 patients) were women. Good baseline comparability was found between the two cohorts. No difference was found in terms of Lysholm Score, ROM, Tegner Scale, IKDC, arthrometer laxity, drawer test, and Telos stress radiography. No difference was found in the rates of anterior knee pain and revision.

CONCLUSION

Allografts can be considered a suitable alternative to autografts for PCL reconstruction.

LEVEL OF EVIDENCE

III.

Minimizing risk of iatrogenic nerve injury during peroneus longus tendon autograft harvest: a cadaveric study at different ankle or knee positions

PURPOSE

To evaluate the distances using ultrasound between the superficial peroneal nerve (SPN) and sural nerve along the peroneus longus tendon (PLT) autograft harvest path at different ankle or knee positions in order to minimize risk of iatrogenic nerve injury during PLT autograft harvest.

METHODS

Twenty-four fresh-frozen human cadaveric lower extremities were used to harvest a full-thickness PLT autograft with a tendon stripper. Four specimens were utilized to validate correct identification of nerves under ultrasound. Sonographically guided perineural injections were performed at the start point and end point of the PLT harvest path using coloured latex, followed by dissection with gross inspection. Using ultrasound, the distance from the peroneus brevis muscle to the sural nerve at different ankle positions (20° dorsiflexion, neutral, and 20° plantarflexion) was measured, and the distance from the end of the tendon stripper to the SPN at different knee positions (full extension and 90° flexion) was also measured. Measurements were performed by two separate observers using ImageJ software.

RESULTS

Cadaveric dissection showed the presence of latex around nerves in all four specimens. The average distance from the brevis muscle to the sural nerve increased significantly from dorsiflexion to plantarflexion. The shortest distance from the tenodesis site to the sural nerve was 5.8 ± 1.7 mm. There was no significant difference from the end of the tendon stripper to the SPN between full extension or 90° flexion of the knee.

CONCLUSION

When harvesting the PLT, it is recommended to place the ankle at plantarflexion. The knee at full extension or 90° flexion had no effect. Joint positions at the time of graft harvest should be monitored to reduce risks of iatrogenic nerve injury.

Hamstring, bone-patellar tendon-bone, quadriceps and peroneus longus tendon autografts for primary isolated posterior cruciate ligament reconstruction: a systematic review

INTRODUCTION

Several autografts are available to reconstruct the posterior cruciate ligament (PCL).

SOURCE OF DATA

Current scientific literature published in PubMed, Google scholar, Embase and Scopus.

AREAS OF AGREEMENT

Hamstring, bone-patellar tendon-bone (BPTB), quadriceps and peroneus longus (PLT) are the most common tendon autografts used for primary isolated PCL reconstruction.

AREAS OF CONTROVERSY

The optimal tendon source for PCL reconstruction remains nevertheless debated. Identifying the most suitable tendon autograft could assist the surgeon during primary PCL reconstruction.

GROWING POINTS

The present study compared the outcome of PCL reconstruction using hamstring, BPTB, quadriceps and PLT autografts. The focus was on patient-reported outcome measures (PROMs), joint laxity, range of motion and complications.

AREAS TIMELY FOR DEVELOPING RESEARCH

All autografts are viable options for PCL reconstruction, with BTB and hamstring autografts demonstrating superior PROMs. However, further clinical investigations are required to determine the ideal autograft construct.

A retrospective cohort study of anterior half peroneus longus tendon vs hamstring tendon for anterior cruciate ligament reconstruction: A minimum 3-years follow-up

Background: The anterior half of the peroneus longus tendon (AHPLT) has recently gained popularity to become the alternate graft choice for anterior cruciate ligament reconstruction due to its acceptable biomechanical properties, easy and safe to harvest. Methods: A retrospective study was conducted to compare the results of anterior cruciate ligament (ACL) reconstruction with AHPLT and hamstring graft at the minimum of 3 years follow-up. Knee stability, International Knee Documentation Committee (IKDC) subjective score and Tegner activity level were collected. Results: There was no clinical significance regarding physical examination. Postoperative IKDC score was higher in the hamstring group compared with AHPLT group. Multiple regression analysis was done. The parsimonious model revealed graft types and gender were the most optimal variables explained postoperative IKDC score. Conclusion: AHPLT graft can be an alternative choice to conventional graft for single anatomic ACL reconstruction with less donor site morbidity, however there must be concern for smaller graft in short and thin female patients.

Single-stage versus two-stage reconstruction in chronic multi ligament knee injury

BACKGROUND

Multi ligament knee injury (MLKI) refers to the disruption of at least 2 of the 4 major knee ligaments. These injuries are managed in single and two-stage surgeries however, treatment guidelines for best practice are unsettled. There is no study in the literature that compares single and two-stage surgery for the management of chronic multiligament knee injury. Therefore, the aim of this study was to compare the functional outcome between single-stage and two-stage surgical fixation in chronic multi-ligament knee injury.

METHODS

Twenty seven patients with chronic MLKI with at least 2 years of follow up were included. Fourteen patients underwent reconstruction of torn ligaments in a single-stage operation (Group I) and 13 patients underwent reconstruction of torn ligaments in two stages (Group II). Assessment of clinical outcome was done with IKDC knee score, TEGNER LYSHOLM knee score, range of movement and laxity tests (Anterior drawer test, Lachman, Posterior drawer test, pivot shift test, dial test, varus and valgus stress test).

RESULTS

At final follow up, there was no significant difference in post-operative IKDC knee scores in group I and group II (84.7±7.1 and 81.4±8.4 respectively, p=0.3) and Lysholm scores (85.8±8.3 and 80.9±8.3 respectively, p=0.1), range of movement (133.2±5.7 and 131.5±6.6 respectively, p=0.5) and all the patients regained full extension. At the final follow up 12/14 patients (85.7%) in group I and 11/13 patients (84.6%) in group II had a negative/grade 1 anterior drawer test (p=0.6), 14/14 (100%) in group I and 13/13 (100%) patients had negative/grade 1 lachman test (p=0.6), 13/14 patients (92.8%) in group I and 13/13 patients (100%) patients in group II had negative/grade 1 pivot shift test (p=0.4), 9/10 patients (90%) in group I and 12/13 patients (92.3%) in group II had negative/grade 1 posterior drawer (p=0.6), 6/6 patients (100%) in group I and 6/7 patients (85.7%) in group II had negative/grade 1 dial test (p=0.3), 5/6 patients (83.3%) in group I and 5/7 patients (71.4%) in group II had negative/grade 1 varus stress test (p=0.4), 6/7 patients (85.7%) in group I and 7/7 patients (100%) in group II had negative/grade 1 valgus stress test (p=0.1).

CONCLUSION

Chronic MLKI managed by single stage and two stage reconstruction provides similar functional outcomes.

LEVEL OF EVIDENCE

Level III Retrospective Cohort Study.

Single versus double bundle in posterior cruciate ligament (PCL) reconstruction: a meta-analysis

Posterior cruciate ligament (PCL) reconstruction can be performed using single bundle (SB) and double bundle (DB) techniques. The present study investigated whether DB PCL reconstruction is superior to SB reconstruction in terms of patient reported outcome measures (PROMs) and joint stability. In December 2021 Embase, Google Scholar, Pubmed, Scopus databases were accessed. All clinical trials comparing SB versus DB reconstruction to address PCL insufficiency in skeletally mature patients were considered. Data from 483 procedures were retrieved. The mean follow-up was 31.0 (28.0 to 107.6) months, and the mean timespan between injury and surgery was 11.3 (6 to 37) months. The mean age of the patients was 29.3 ± 3.8 years. 85 of 483 patients (18%) were women. At a mean of 31.0 months post reconstruction, ROM (P = 0.03) was slightly greater in the SB group, while the Tegner score (P = 0.03) and the Telos stress (P = 0.04) were more favorable in the DB cohort. Similarity was found in instrumental laxity (P = 0.4) and Lysholm score (P = 0.3). The current evidence does not support the use of DB techniques for PCL reconstruction. Both methods could restore knee stability and motion with satisfactory short term patient reported outcome measures. Further high quality clinical trials are required to validate these results on a larger scale.

Low to moderate risk of nerve damage during peroneus longus tendon autograft harvest

PURPOSE

This study aims to evaluate the proximity of the tendon stripper to both the peroneal and sural nerves during peroneus longus tendon (PLT) autograft harvesting.

METHODS

Ten fresh-frozen human cadaveric lower extremities were used to harvest a full-thickness PLT autograft using a standard closed blunt-ended tendon stripper. The distance to the sural nerve from the PLT (at 0, 1, 2 and 3 cm proximal to lateral malleolus (LM), and the distance to the peroneal nerve and its branches from the end of the tendon stripper were measured by two separate observers using ImageJ software.

RESULTS

The average distance from the PLT to the sural nerve increased significantly from 0 to 2 cm proximal to LM. The average distance to the sural nerve at the LM was 4.9 ± 1.5 mm and increased to 10.8 ± 2.4 mm (2 cm proximal to LM). The average distance from the tendon stripper to the deep peroneal nerve was 52.9 ± 11.4 mm. The average distance to the PLT branch of peroneal nerve was 29.3 ± 4.2 mm. The superficial peroneal nerve, which coursed parallel and deep to the tendon stripper, was on average 5.2 ± 0.7 mm from the end of the stripper. No transection injuries of the nerves were observed in any of the ten legs after harvesting.

CONCLUSION

This cadaver study found during a full-thickness PLT harvest, the distances between the tendon stripper and the nerves were greater than 5 mm with an initial incision at 2 cm proximal to LM which is recommended.

Peroneus longus tendon autograft has functional outcomes comparable to hamstring tendon autograft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis

PURPOSE

This review aimed to assess whether peroneus longus tendon (PLT) autograft would have comparable functional outcomes and graft survival rates when compared to hamstring tendon (HT) autograft for anterior cruciate ligament (ACL) reconstruction.

METHODS

PubMed, Web of Science, Cochrane Library, Ovid (MEDICINE), and EMBASE databases were queried for original articles from clinical studies including the keywords: ACL reconstruction and PLT autograft. Studies comparing PLT autograft versus HT autograft were included in this analysis and the following data were extracted from studies meeting the inclusion criteria: graft diameter, functional outcomes (Tegner activity scale, Lysholm score, and International Knee Documentation Committee (IKDC) subjective score), knee laxity (Lachman test), and complications (donor site pain or paresthesia, graft failure). Besides, the American Orthopaedic Foot and Ankle Society (AOFAS) scale and the Foot and Ankle Disability Index (FADI) pre-operation and at last follow-up were also compared among patients using PLT autograft. Meta-analysis was applied using Review Manager 5.3 and p < 0.05 was considered statistically significant.

RESULTS

Twenty-three studies including 925 patients with ACL reconstruction met inclusion criteria. Of these, 5 studies included a direct comparison of PLT autograft (164 patients) versus HT autograft (174 patients). No significant difference was observed between PLT and HT autografts for Tegner activity scale, Lachman test, donor site pain, or graft failure. However, PLT groups demonstrated better Lysholm score (mean difference between PLT and HT groups, 1.55; 95% CI 0.20-2.89; p = 0.02) and IKDC subjective score (mean difference between PLT and HT groups, 3.24; 95% CI 0.29-6.19; p = 0.03). No difference of FADI was found (n.s.) but AOFAS was slightly decreased at last post-operative follow-up for patients with PLT autograft compared with pre-operative scores (mean difference of 0.31, 95% CI 0.07-0.54, p = 0.01).

CONCLUSION

PLT autograft demonstrated comparable functional outcomes and graft survival rates compared with HT autograft for ACL reconstruction. However, a slight decrease in AOFAS score should be considered during surgical planning. Hence, the PLT is a suitable autograft harvested outside the knee for ACL reconstruction to avoid the complication of quadriceps-hamstring imbalance which can occur when harvesting autografts from the knee.

LEVEL OF EVIDENCE

Level II.

Anterior Half of the Peroneus Longus Tendon Combined with Semitendinosus and Gracilis Tendons for Anterior Cruciate Ligament Reconstruction: An Athlete Case Report

In clinical practice, it is observed that the hamstring tendon graft, despite being first choice in knee ligament reconstruction, may not present adequate size. Therefore, it becomes necessary to search for other graft alternatives. In this context, the peroneus longus tendon arises as an option to replace or complement other grafts. The surgeon can opt to use the tendon in its totality or only its anterior half, presenting adequate length, diameter, and biomechanics, without major repercussions for the donor site. In this study, we report a case of an athlete in which the autologous hamstring tendon graft did not present the adequate diameter for anterior cruciate ligament reconstruction. It was, then, necessary to use the anterior half of the peroneus longus tendon.

Posterior cruciate ligament reconstruction with peroneus longus tendon versus hamstring tendon: a comparison of functional outcome and donor site morbidity

PURPOSE

This study aimed to evaluate the differences in clinical outcome and donor site morbidity between the Peroneus Longus Tendon (PLT) and Hamstring Tendon (HT) in single-bundle Posterior Cruciate Ligament (PCL) reconstruction.

METHODS

Patients with an isolated PCL injury underwent single-bundle PCL reconstruction using consecutive sampling. Patients were allocated into two groups (PLT and HT) and prospectively observed. The tendon graft diameter was measured intraoperatively. Functional scores (IKDC, Lysholm, and modified Cincinnati scores) were recorded preoperatively and 2 years postoperatively. The thigh circumference and functional score according to the Foot and Ankle Disability Index (FADI) and American Orthopedic Foot and Ankle Society (AOFAS) were recorded to evaluate the morbidities in the ankle.

RESULTS

Fifty-five patients (hamstring n = 27, peroneus n = 28) met the inclusion criteria. The diameter of the PLT graft (8.2 ± 0.6 mm) was comparable to that of the HT graft (8.3 ± 0.5 mm). Both groups had excellent postoperative knee functional outcome scores. The mean AOFAS and FADI scores were excellent, with no difference in thigh circumference between the groups.

CONCLUSION

PLT is a good choice as a graft in PCL reconstruction at the 2-year follow-up, with minimal donor site morbidity.

LEVEL OF EVIDENCE

II.

Anterior Cruciate and Anterolateral Ligament Reconstruction Using Hamstring and Peroneus Longus Tendons: Surgical Technique Description

The main objective of this study is to describe a surgical technique that combines intra- and extra-articular techniques using the semitendinosus, gracilis, and peroneus longus to perform reconstruction of the anterior cruciate ligament and anterolateral ligament. This technique offers a more stable, fast, low-cost, and widely accessible procedure and consists of drilling 3 tunnels-1 femoral and 2 tibial tunnels-in which the grafts are fixed with interference screws. The fact that the peroneus longus graft is long and thick allows for robust reconstruction of the aforementioned ligaments.

Outcomes of one-stage reconstruction for chronic multiligament injuries of knee

PURPOSE

This article aims to evaluate patterns of chronic multiligament injuries and outcomes of treatment with single-stage reconstruction using autografts.

METHODS

All patients with clinicoradiologically diagnosed multiligament knee injury (MKI) were included in this prospective observational study. As the time since injury was more than 6 weeks in all of the patients, they were categorized as having chronic MKI. Patients were assessed clinically for laxity, and the diagnosis was confirmed radiologically. Ipsilateral hamstring tendons were used for medial collateral ligament (MCL) or posterolateral corner reconstruction in a patient with Schenck knee dislocation (KD) type III. In these cases, the posterior cruciate ligament (PCL) and anterior cruciate ligament (ACL) were reconstructed by using the peroneus longus and contralateral hamstring tendons respectively. Ipsilateral hamstring tendons were used for ACL reconstruction and an ipsilateral peroneus longus tendon graft was used for reconstruction of the PCL in a KD type II injury. In two cases of KD type IV injury, the lateral laxity was only grade II and was managed conservatively; the rest of the ligaments were addressed like a KD type III injury. Outcome evaluation was done using a visual analogue scale (VAS) for pain, International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity level, preoperatively and postoperatively at 2 years' follow-up.

RESULTS

A total of 27 patients of mean age 33.48 ± 9.9 years with MKI were included in the study. The patients were classified as eight KD type II, 17 KD type III, and two KD type IV. The majority of the patients had associated meniscal (59.2%) or chondral (40.7%) injuries. At the 2 years' follow-up visit, there were significant improvements in VAS score (p = 0.0001) IKDC score (p = 0.0001), Lysholm score (p = 0.0001), and range of motion (p = 0.001). None of the patients had residual laxity on clinical examination of the knee joint at the 2 years' follow-up. All but two of the patients went back to their previous activity level. These two patients had progressive knee arthritis and needed knee arthroplasty.

CONCLUSION

Single-stage surgical reconstruction for chronic MKI has favourable functional outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

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.

Lateral Meniscus Replacement Using Peroneus Longus Tendon Autograft

Nowadays, several techniques are available for preserving the lateral aspect of the knee after meniscectomy; meniscus transplantation is the gold standard, and meniscus scaffold implantation is an effective alternative. However, meniscus transplantation is technically difficult and has many potential complications, whereas scaffolds resorb over time. Autografts are commonly used for labroplasty in shoulder and hip surgeries. We attempted to adapt this technique to the knee, using autografts for meniscus replacement. In this report, we describe a meniscus-replacement technique, using a peroneus longus autograft, for lateral meniscus deficits. This technique significantly simplifies the procedure and is cost effective, and thus can be considered as an alternative technique for preventing osteoarthritis of the lateral aspect of the knee.

Influence of anthropometric features on peroneus longus graft diameter in Anterior Cruciate Ligament reconstruction: A cohort study

Background

Anterior Cruciate Ligament (ACL) is the most common ligament injury during sports activities that was treated with ACL reconstruction. Nowadays, peroneus longus is used in ACL reconstruction. However, it is difficult to predict the peroneus longus graft diameter for ACL reconstruction. Thus, preoperative measurements are very important to predict peroneus longus autograft for ACL reconstruction.

Methods

A cohort retrospective study was conducted using consecutive sampling method from February 2016 until October 2017 in our center. We recorded patients’ characteristics include gender, age, body weight, height, and Body Mass Index (BMI) preoperatively. We measured peroneus longus graft diameter intraoperatively, and analysed data using Spearman correlation.

Results

Thirty-nine patients met inclusion criteria. There were 28 males and 11 females in the peroneus group. From the patients' mean characteristics, age was 25.10 ± 9.16, body weight 71.23 ± 14.17, height 169.13 ± 8.81, and BMI 20.96 ± 3.44. Intraoperative peroneus longus diameter measurement was 8.56 ± 0.82. Spearman correlation showed significant correlation between intraoperative peroneus longus diameter with patient's height, body weight, and BMI with p < 0.05.

Conclusion

Patients’ characteristics including gender, height, weight, and BMI in preoperative measurements can predict peoneus longus graft diameter intraoperatively.

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Gender.

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Height.

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Weight.

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Body Mass Index.

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Peroneus longus tendon diameter.

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Patients' characteristics in preoperative measurements can predict graft diameter intraoperatively.

Clinical Outcome of Arthroscopic Posterior Cruciate Ligament Reconstruction with Adjustable-Loop Femoral Cortical Suspension Devices

BACKGROUND

Incidence of isolated posterior cruciate ligament (PCL) injury is lower than PCL rupture is associated with other knee injuries. Adjustable loop femoral cortical suspension device is commonly used for femoral graft fixation during PCL reconstruction.

AIM

This study purpose is to describe the functional outcome of PCL reconstruction using an adjustable loop femoral cortical suspension device.

METHODS

This study used prospective design with consecutive sampling. All patients underwent PCL reconstruction with adjustable loop femoral cortical suspension devices using peroneus longus tendon autograft. Patients were evaluated at 6 months after surgery using posterior drawer test and functional outcome scoring system (Lysholm knee score, Cincinnati Score and International Knee Documentation Committee (IKDC) score).

RESULTS

20 patients were enrolled in this study with a mean age of 27.65 ± 9.78. Lysholm knee means the score was improved from 59.80 ± 18.73 pre-operative and 80.55 ± 11.72 post-operative (p < 0.05). Cincinnati mean score was improved from 52.01 ± 20.29 pre-operative to 72.95 ± 15.26 post-operative (p < 0.05). IKDC mean score was improved from 48.36 ± 13.18 at pre-operative to 72.5 ± 13.13 post-operative (p < 0.05).

CONCLUSION

PCL reconstruction using adjustable loop femoral cortical suspension device using peroneus longus tendon autograft showed good clinical outcome and knee functional outcome (Lysholm, Cincinnati, and IKDC score) at 6 months follow-up.