Peroneus longus autograft versus hamstring tendon autograft in primary anterior cruciate ligament reconstruction: a systematic review and meta-analysis of randomised controlled trials.

Abstract

Background: 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).

Methods: 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.

Results: 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.

Conclusion: 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.