Is a peroneal tendon graft (peroneal tendon graft) a suitable option for anterior cruciate ligament (ACL) reconstruction in a patient with a torn ACL?

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Peroneal Tendon Graft for ACL Reconstruction

Peroneal tendon autograft is a viable alternative to standard hamstring or patellar tendon grafts for ACL reconstruction, with comparable functional outcomes and fewer donor-site complications, though it is not currently recommended as a first-line option by major orthopedic guidelines.

Guideline-Recommended First-Line Grafts

The American Academy of Orthopaedic Surgeons establishes a clear hierarchy for graft selection in skeletally mature patients 1, 2:

  • Bone-patellar tendon-bone (BPTB) autograft should be favored when minimizing graft failure and infection risk is the priority 1, 2
  • Hamstring tendon autograft should be preferred when reducing anterior knee pain or kneeling pain is critical 1, 2
  • Allograft options (patellar tendon or Achilles) are reasonable for revision cases or when ipsilateral grafts are unavailable 3

Notably, peroneal tendon is mentioned among allograft options in the literature but is not specifically endorsed in current AAOS guidelines 4.

Evidence Supporting Peroneal Tendon as an Alternative

Biomechanical Properties

The peroneal longus tendon demonstrates superior biomechanical strength compared to native ACL 5:

  • The ultimate tensile strength of doubled peroneal longus tendon is significantly higher than native ACL 5
  • Doubled peroneal longus tendon has comparable tensile strength to quadrupled hamstring tendon 5

Clinical Outcomes

Recent high-quality research demonstrates non-inferior results 6, 7:

  • Knee function scores: A 2024 meta-analysis of 683 patients showed no significant differences in Lysholm or IKDC scores between peroneal longus and hamstring grafts at 12 and 24 months 6
  • Graft diameter: No significant difference in graft diameter between peroneal longus and hamstring tendons 6
  • Knee stability: A prospective study of 439 patients showed 97.43% had negative pivot shift tests at 24 months, with only 7.70% having mildly positive Lachman tests 7

Donor-Site Morbidity Advantage

Peroneal tendon grafts demonstrate significantly fewer donor-site complications compared to hamstring grafts 6:

  • Ankle function remains excellent post-harvest, with impressive FADI and AOFAS scores at 2 years 7
  • No significant differences in pre- and postoperative biomechanical testing of the donor ankle 5
  • Hop tests (single, triple, and crossover) show preserved ankle function 7

Clinical Decision Algorithm for Peroneal Tendon Use

Consider peroneal tendon graft when:

  • Patient has concomitant grade III MCL injury requiring ACL reconstruction 5
  • Previous hamstring or patellar tendon harvest makes standard autografts unavailable 4
  • Patient wishes to avoid anterior knee pain associated with BPTB 6, 7
  • Patient wishes to avoid hamstring weakness 6, 7
  • Adequate graft diameter (typically 7-9mm when doubled) can be obtained 6

Avoid peroneal tendon graft when:

  • Patient has pre-existing ankle instability or peroneal tendon pathology 7
  • Patient is under 25 years old and maximum graft stability is critical (use BPTB instead) 1, 2
  • Surgeon lacks experience with peroneal tendon harvest technique 7

Surgical Technique Considerations

The peroneal longus tendon is typically harvested as a doubled graft through a small lateral ankle incision 7, 5:

  • Harvest does not compromise ankle stability when performed correctly 5
  • Graft preparation is similar to hamstring tendon technique 6
  • Both single-bundle and double-bundle reconstruction techniques can be utilized 1

Critical Timing Consideration

Regardless of graft choice, early reconstruction within 3 months of injury is strongly recommended to reduce risk of additional cartilage and meniscal damage 1, 2.

Common Pitfalls to Avoid

  • Do not use peroneal tendon in patients with ankle pathology without thorough preoperative ankle assessment 7
  • Do not delay reconstruction beyond 3 months in young, active patients regardless of graft choice 1, 2
  • Do not use functional knee braces routinely after isolated primary ACL reconstruction as they provide no clinical benefit 1, 2
  • Ensure adequate graft diameter before committing to peroneal tendon harvest 6

Postoperative Rehabilitation

Standard ACL rehabilitation protocols apply 1:

  • Combine strength training and motor control exercises 1
  • Use criterion-based progression rather than time-based alone 2
  • Address modifiable risk factors including weight control and quadriceps strengthening 1

References

1
Guideline

Treatment of Anterior Cruciate Ligament Injuries with Medial Meniscus Lesions and Risk of Osteoarthritis

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Guideline

Artificial Grafts for ACL Reconstruction

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Guideline

Bone-Patellar Tendon-Bone vs Quadriceps Tendon for ACL Reconstruction

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Research

Graft Selection in Anterior Cruciate Ligament Reconstruction.

Sports medicine and arthroscopy review, 2020

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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