European Journal of Cardiovascular Medicine

Knee stability is mainly provided by ligaments and involves the cruciate ligaments. The anterior cruciate ligament (ACL) and posterior cruciate ligament are the most important ones. ^[1] ACL plays an important role in stabilizing knee joints against translational and rotational forces. ACL tear may lead to knee instability, meniscus tear, and subsequent osteoarthritis. ^[2]

ACL reconstruction is a common procedure in orthopedics surgery. ACL reconstruction can be performed using a variety of different surgical techniques as well as different graft materials. Nowadays, bone-patellar tendon-bone (BPTB) and four-strand hamstring (HS) autografts are the two most common autografts used for ACL reconstruction and each has its advantages and disadvantages. Although the BPTB autograft has been a gold standard, 40-60% of patients who have undergone ACL reconstruction using patellar tendon autograft have an anterior knee problem that can jeopardize the activity for the patients, who spend a lot of time on their knee for culture and job. ^[3] Quadrupled HS has become an increasingly popular alternative autograft and recent reports indicate less donor morbidity; however, the HS harvest medially can damage the saphenous nerve and could potentially lead to instability of the medial knee joint if ACL rupture accompanied by medial collateral ligament injury. ^[4]

An ideal autograft should have an acceptable amount of strength, and size and be easily and safely harvested. Surgical site infection may occur in patients with skin and soft-tissue injury in the area of pes anserine insertion from where the medial HS graft is harvested. In addition, another feasible autograft would be useful in revision situations or as a supplement to other autograft choices. The peroneus longus (PL) tendon may be a potential autograft, as it is superficial in the lateral aspect of the distal leg and can be easily harvested. Important functions of PL include plantar flexion of the ankle, eversion of the sole, maintenance of the transverse arch, and steadying of the leg on the foot. ^[5]

Previously, PL was used as a source of autologous tendon graft, but studies about its side effects are insufficient. ^[6] Studies have shown that the PL that had been taken did not have any effect on walking and did not interfere with ankle stability. Biomechanical evaluations of the properties of complete PL grafts have been done recently and revealed that both the strength and stiffness of complete PL grafts are suitable for knee ACL reconstruction. ^[7]

Thus, the purpose of this study is to compare the impact of HS graft and PL graft on the knee using knee functional scores. This study was undertaken at a tertiary care teaching center in India in patients with ACL injury of the knee diagnosed clinically and by magnetic resonance imaging (MRI) (if indicated), who underwent ACL reconstruction using HS graft and PL graft, by assessing clinical outcomes in the knee using International Knee Documentation Committee (IKDC) Score and Modified Cincinnati score (MCS).

This prospective cohort study was conducted in the Orthopedics Department, a tertiary care centre in India, after obtaining formal approval from the institute's ethical committee. This study was done in June 2022 to August 2023, with 50 patients with ages between 16 and 50 years of either gender who presented with an isolated symptomatic ACL rupture being included after proper written informed consent. Patients were excluded if they had other associated intraarticular pathology, stiffness of the joint, multiligamentous injury, or associated fractures around the knee joint.

All included patients were randomly allocated into HT and PLT groups, operated on, and then rehabilitated. For both groups, patients were made to fill out the International Knee Documentation Committee (IKDC) score form, the Lysholm score form, and the ankle-hindfoot score form at the preoperative stage and during subsequent follow-up periods. The thigh circumference of the injured limb was measured 15 cm proximal to the superior pole of the patella and compared with the contralateral healthy side. Similarly, all the patients were also assessed for knee stability using clinical tests (the anterior drawer, Lachman, and pivot shift tests). The procedure and arthroscopic technique.

In our study, 50 patients of ACL injury were operated. There were 25 (50%) patients in Group H (Hamstring tendon graft) and 25 (50%) patients in Group P (Peroneus Longus tendon graft). The mean age of patients in Group-H was 35.15 ± 11.19 years (range 20-54 years) and in Group-P, it was 33.95 ± 8.99 years (range 19-42 years). In both groups, males predominated in terms of gender (72% in group H and 80% in group P). In Group-H, most of the patients had left side involvement and in Group-P, most of the patients had right side involvement. The mean height in Group-H was 169.00 ± 9.07 cm and in Group-P, it was 168.99 ± 7.58 cm. The mean weight in Group-H was 65.45 ± 8.60 kg and in Group-P, it was 67.29 ± 8.38 kg. In both groups, majority of patients sustained injury due to road traffic accident, and sports related injuries were relatively less in our study. The average graft diameter of Group H was 10.5 ± 0.52 mm and that of Group P was 10.6 ± 0.39 mm. 

Table No. 1: - Summary of Patient Data.

Table No. 2: - Comparison of mean Lysholm Score between the two groups.

Unpaired ‘t’ test applied. P value <0.05 was taken as statistically significant

In both groups, the mean Lysholm score showed an improvement over the period of follow-ups, from preoperative to 6 months, but the mean differences in Lysholm scores between the two groups at each follow-up were found to be statistically not significant.

The mean Lysholm scores were comparable between the two groups at each follow-up.

Table No. 3: - Comparison of mean IKDC Score between the two groups

Unpaired ‘t’ test applied. P value <0.05 was taken as statistically significant

 In both groups, the mean IKDC score showed an improvement over the period of follow-ups, from preoperative to 6 months, but the mean differences in IKDC scores between the two groups at each follow-up were found to be statistically not significant.

 The mean IKDC scores were comparable between the two groups at each follow-up.

Table No. 4: - Comparison of postoperative complications between the two groups.

Fisher’s Exact test applied. A P value of <0.05 was taken as statistically significant

 In Group-H, 6 (24%) patients complained of knee stiffness and 1 (4%) patient required arthroscopic debridement due to infection.  In Group-P, 1 (4%) patient complained of knee stiffness and 1 (4%) patient required arthroscopic debridement due to infection. The incidence of knee stiffness was comparable between the two groups (Fisher’s exact test P value = 0.348) and similarly, the incidence of requirement of arthroscopic debridement was also comparable between the two groups (Fisher’s exact test P value = 1.000). The postoperative complication rate between the two groups were comparable.

A systematic review and meta-analysis of functional outcome following hamstrings and peroneus longus autograft in ACL reconstruction in 925 patients. Jinshen et al. observed that Lysholm and IKDC score has improved better in peroneus longus group than hamstrings group. There was no difference in FADI but minimally reduced AOFAS score in peroneus longus group. He concluded that peroneus longus can be an ideal graft and can circumvent the complication of imbalance between quadriceps-hamstrings which happens following harvesting the hamstrings tendon. ^[14]

There was no limitation of ankle eversion and first ray plantar flexion with good ankle motor strength. AOFAS analysis was 100% at end of 1 year and Wiradiputra et al. concluded that peroneus longus can be used as the first option in ACL reconstruction. ^[15]

A 2-year follow-up of patients who underwent peroneus longus graft for ACL reconstruction by Sholahuddin observed that excellent IKDC, MCS, Tegner-Lysholm score, AOFAS, FADI scores. Good graft diameter was harvested, thigh hypotrophy was less, with excellent ankle function and a better serial hop test result was achieved. ^[16]

Kusumastutia have done an observational analytical study retrospectively in 75 patients for 1 year. There was an improvement in mean IKDC, MCS, Tegner-Lysholm score, KSS (function), AOFAS and FADI scores at the end of 1 year compared to pre-operative. Eversion and plantar flexion strength were not significantly different between contralateral normal ankle and donor site. 3 patients had neuropraxia in the HST group and concluded that peroneus longus can be used as a promising graft for ACL reconstruction. ^[17]

PLT has a greater ultimate tensile load, more thickness and length, less graft harvesting time, and almost no donor site morbidity and has a good functional outcome of the knee, making it an effective and safe autograft option. So, PL autograft can be a promising graft of choice in the reconstruction of the ACL and can be much more beneficial in simultaneous multi-ligament injury repair in the knee joint.

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