Is any tendon from the lateral leg used for Anterior Cruciate Ligament (ACL) reconstruction in a patient with no significant medical history or allergies?

Lateral Leg Tendons for ACL Reconstruction

No tendons from the lateral leg are routinely used for ACL reconstruction. The standard autograft options are bone-patellar tendon-bone (BPTB) from the anterior knee, hamstring tendons (semitendinosus and gracilis) from the medial knee, and quadriceps tendon from the anterior thigh 1, 2, 3.

Standard Autograft Options

Primary Choices

• Bone-patellar tendon-bone (BPTB) is the preferred autograft when minimizing graft failure risk is the priority, particularly for young, high-demand athletes 1, 2, 3
• Hamstring tendons (semitendinosus and gracilis from the medial knee) are favored when avoiding anterior knee pain is critical 1, 2
• Quadriceps tendon is an emerging alternative that can be harvested with or without a bone block for both primary and revision reconstruction 4

Emerging Alternative: Peroneus Longus

• Peroneus longus tendon from the lateral leg has been studied as an alternative autograft option, showing similar functional outcomes to hamstring grafts at 5-year follow-up 5
• This graft provides adequate diameter (mean 8.9 mm) and comparable knee stability to hamstring grafts 5
• However, this remains investigational and is not included in current AAOS guidelines as a standard option 1, 2, 3

Recommended Graft Selection Algorithm

For Young, High-Activity Patients

• First choice: BPTB autograft provides superior stability, lowest graft failure rates, and reduced infection risk 1, 2, 3
• Trade-off includes higher risk of anterior/kneeling pain 1, 3

For Patients Prioritizing Comfort

• Hamstring autograft reduces anterior and kneeling pain compared to BPTB 1, 2, 3
• Consider adding lateral extra-articular augmentation to reduce re-rupture risk with hamstring grafts 2, 3

For Revision Cases or When Ipsilateral Grafts Unavailable

• Allograft options (patellar tendon or Achilles) are reasonable alternatives 6, 7, 8
• Achilles allograft shows favorable outcomes in patients over 30 years old 8

Critical Clinical Pearls

Timing

• Perform reconstruction within 3 months of injury to reduce risk of additional cartilage and meniscal damage 2, 3

Surgical Technique

• Both single-bundle and double-bundle techniques show equivalent outcomes, allowing surgeon preference to guide selection 2, 3

Common Pitfall to Avoid

• Do not delay reconstruction beyond 3 months in young, active patients as this increases risk of secondary meniscal and cartilage injury 2, 3
• Functional knee braces are not recommended for routine use after isolated primary ACL reconstruction as they confer no clinical benefit 6, 3