Peroneus longus tendon autograft for anterior cruciate ligament reconstruction: Current evidence, donor-site complications and patient selection.

Abstract

The search for the ideal autograft for anterior cruciate ligament (ACL) reconstruction (ACLR) remains a longstanding challenge in orthopaedic surgery, as each available graft possesses distinct advantages and inherent limitations. The peroneus longus tendon (PLT) has emerged as an alternative autograft, expanding graft options without further compromising the injured knee. Initially regarded with caution because of concerns regarding its role in foot and ankle biomechanics, the PLT has evolved into an increasingly recognised alternative autograft option supported by a growing body of anatomical, biomechanical and clinical evidence. The accumulating evidence suggests that the PLT provides reliable graft characteristics, while available comparative studies report broadly similar short- to mid-term clinical outcomes to established autografts and generally favourable donor-site function. However, the predominantly retrospective and heterogeneous evidence base does not establish graft equivalence or noninferiority. Although important questions remain, particularly regarding sport-specific ankle performance in high-demand athletes, long-term donor-site consequences and optimal harvest techniques, the available evidence supports consideration of the PLT as an additional autograft option for ACLR. Rather than establishing graft superiority, this editorial synthesises the current evidence, highlights the strengths and limitations of the PLT, and provides a practical framework for individualised ACL graft selection.