Peroneus longus autograft can be recommended as a superior graft to hamstring tendon in single-bundle ACL reconstruction



A peroneus longus tendon autograft is used in many orthopaedic procedures and it is biomechanically comparable to a hamstring tendon autograft. Despite its potential, there are few studies that have evaluated the use of the peroneus longus tendon in ACL reconstruction. The aim of this study was to compare the clinical outcome and donor site morbidity of ACL reconstruction with hamstring tendon autografts versus peroneus longus tendon autografts in patients with an isolated ACL injury.


Patients who underwent isolated single-bundle ACL reconstruction were allocated to two groups (hamstring and peroneus longus) and observed prospectively. Graft diameter was measured intraoperatively. Functional scores (IKDC, modified Cincinnati and Lysholm scores) were recorded preoperatively and 1 year after surgery. Donor site morbidities were assessed with thigh circumference measurements and ankle scoring with the AOFAS and FADI.


Fifty-two patients (hamstring n = 28, peroneus n = 24) met the inclusion criteria. The peroneus longus graft diameter (8.8 ± 0.7 mm) was significantly larger than the hamstring diameter (8.2 ± 0.8 mm) (p = 0.012). There were no significant differences between the pre- and 1-year postoperative score between the hamstring and peroneus longus groups in the IKDC (n.s), modified Cincinnati (n.s), and Lysholm (n.s). The mean for the AOFAS was 97.3 ± 4.2 and for the FADI 98 ± 3.4 in the peroneus longus group, with a significant decrease in thigh circumference in the hamstring group (p = 0.002).


Anterior cruciate ligament reconstruction with peroneus longus autografts produces a functional score (IKDC, modified Cincinnati, Lysholm) comparable to that of hamstring autografts at a 1-year follow-up, with the advantages of larger graft diameter, less thigh hypotrophy and excellent ankle function based on AOFAS and FADI scores.

Level of evidence

Prospective cohort study, Level II.

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Fig. 1



Anterior cruciate ligament


Bone–patellar tendon–bone


Medial patellofemoral ligament


International Knee Documentation Committee


Medial collateral ligament


American Orthopedic Foot and Ankle Score


Foot and Ankle Disability Index


Knee injury and Osteoarthritis Outcome Score


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We would like to thank Dadang R. Sasetyo, MD, for his assistance with patient selection, history taking and obtaining patient consent, and Shinta Primasara, MD, for her help with postoperative functional data collection during patient rehabilitation.


No external funding was used.

Author information




NCB conceived the study, participated in its design, reviewed, edited and finalised the manuscript. SR carried out patient selection consisting of history taking, physical examination and MRI evaluation, explained the study to the patients and obtained the patients’ informed consent, performed all the ACL reconstruction surgery, collected intraoperative study data, reviewed and edited the paper. AIZA collected preoperative data including demographic data, preoperative functional scores and postoperative data, including functional scores and thigh circumference measurements, performed statistical analyses, wrote the paper and prepared the manuscript. AEW performed statistical analyses, wrote the paper and prepared the manuscript. ILG performed statistical analyses and interpretations, reference review, manuscript review and edits. TR co-ordinated the study design with all the authors and reviewed the manuscript. All the authors have read and approved the final manuscript.

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Correspondence to Nicolaas C. Budhiparama.

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Rhatomy, S., Asikin, A.I.Z., Wardani, A.E. et al. Peroneus longus autograft can be recommended as a superior graft to hamstring tendon in single-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 27, 3552–3559 (2019).

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