The anterior cruciate ligament (ACL) is a key stabilizing structure of the knee, primarily responsible for preventing anterior tibial translation and resisting rotational and valgus stresses acting on the joint [1,2]. Given its central biomechanical function, an ACL injury often leads to abnormal joint kinematics and predisposes the knee to secondary degenerative changes and long-term functional impairments if left untreated [3,4]. Reconstruction of the ACL aims to restore stability, prevent further damage, and facilitate return to pre-injury levels of activity. The ideal graft material for ACL reconstruction should closely resemble the native ligament in its mechanical and biological properties, offer secure fixation, promote rapid incorporation, and minimize donor site morbidity. Although a variety of graft options are available, there remains no clear consensus on the most optimal choice, making graft selection an area of ongoing investigation [5].

Among autografts, the semitendinosus tendon has gained widespread acceptance due to its favorable handling characteristics and satisfactory clinical outcomes [5]. However, autografts harvested from the knee, including the semitendinosus, are not without limitations. Issues such as postoperative quadriceps–hamstring imbalance, donor site weakness, and residual joint laxity have been reported [6,7]. In response to these concerns, alternative graft sources located away from the knee joint have been explored. The peroneus longus tendon (PLT), harvested from the lateral compartment of the leg near the ankle, has recently garnered attention as a viable autograft for ACL reconstruction. It offers the benefit of preserving peri-knee structures while demonstrating promising mechanical integrity and compatibility. The use of PLT in ACL reconstruction was first described by Kerimoglu et al. in 2008 [8], and was subsequently adopted and evaluated by Zhao et al. in 2012 and Rhatomy et al. in 2019 [9,10].

In countries where access to allografts or synthetic grafts is limited, the PLT autograft may serve as an effective alternative. With the global prevalence of ACL injuries remaining high, innovations in reconstruction techniques and graft selection continue to be areas of intensive research focus [11]. This study aims to compare the functional outcomes of ACL reconstruction using semitendinosus and peroneus longus tendon autografts, to evaluate the role of arthroscopy in therapeutic knee reconstruction, and to analyze the complications associated with each graft type.

This prospective comparative study was conducted in the Department of Orthopaedics, Saraswati Medical College and Hospital, Unnao, between February 2024 and February 2025, after obtaining approval from the Institutional Ethics Committee. A total of 60 patients diagnosed with anterior cruciate ligament (ACL) tears based on clinical examination and MRI findings were included in the study. All patients underwent arthroscopic ACL reconstruction.

Inclusion Criteria

Patients aged 15–50 years with isolated ACL injuries or ACL injuries associated with grade I or II meniscal tears, who were medically fit for surgery and consented to undergo arthroscopic reconstruction, were included in the study.

Exclusion Criteria

Patients with ACL avulsion injuries, multi-ligamentous knee injuries, meniscal tears requiring meniscal repair or total meniscectomy, intra-articular fractures, congenital or degenerative knee pathologies, collagen disorders, or infected joints were excluded from the study.

Methodology

The study population was divided equally into two groups: 30 patients underwent reconstruction using semitendinosus tendon autografts (Group A), while 30 patients received peroneus longus tendon autografts (Group B). All patients were followed up for a minimum of 6 months and a maximum of 12 months postoperatively.

All surgeries were performed under spinal or epidural anaesthesia using a pneumatic tourniquet. A standardized postoperative rehabilitation protocol was followed for all patients irrespective of graft type.

Surgical Procedure

Arthroscopic Evaluation

All patients underwent diagnostic arthroscopy via an anterolateral viewing portal and anteromedial working portal to confirm the ACL tear and assess associated intra-articular pathology. Any loose bodies or meniscal tears were addressed during the same procedure.

Graft Harvesting and Preparation

Graft Harvest: Semitendinosus Tendon

A 4 cm oblique incision was placed over the anteromedial aspect of the proximal tibia, approximately 4 cm distal to the medial joint line and 3 cm medial to the tibial tuberosity. After incising the skin and subcutaneous tissues, the pes anserinus insertion was visualized. The semitendinosus and gracilis tendons were palpated along the anteromedial tibial border, tracing their course distally. If needed, the incision was extended to facilitate adequate exposure. The sartorial fascia was incised to access the underlying tendons. The semitendinosus tendon was gently dissected from adjacent soft tissues and isolated with the aid of right-angled forceps. Fibrous adhesions were carefully released, and the tendon was secured using Ethibond sutures. A closed tendon stripper was introduced around the tendon and advanced proximally while the knee was flexed to approximately 70°, ensuring controlled counter-traction. Special attention was taken to prevent premature transection at the musculotendinous junction. The stripper was progressed until complete release was achieved and the tendon was successfully harvested.

Graft Harvest Peroneus Longus Tendon:

The surgical procedure began with identification of key anatomical landmarks, including the lateral malleolus and the posterior margin of the fibula. The proposed incision site was marked approximately 2–3 cm superior and 1 cm posterior to the lateral malleolus. To ensure safety and avoid injury to the common peroneal nerve, a reference point was marked about 5 cm distal to the fibular head. A 3 cm longitudinal skin incision was made, extending down to the peroneal retinaculum. The peroneus longus and peroneus brevis tendons were exposed, and careful blunt dissection was carried out to free the peroneus longus tendon from surrounding soft tissue in the proximal direction. The distal end of the peroneus longus was tagged for control. A tenodesis procedure was performed using Ethibond sutures, securing both the peroneus longus and brevis tendons approximately 2 cm distal to the harvest site. The peroneus longus was then transected proximal to the tenodesis. The proximal portion of the tendon was whipstitched using non-absorbable suture material. A closed tendon stripper was introduced and carefully advanced proximally up to approximately 5 cm below the fibular head to avoid peroneal nerve injury. Harvesting was terminated at a minimum distance of three finger-breadths from the fibular head, and the graft was detached with the stripper oriented anteriorly.

Graft Preparation

Following harvest, the graft was meticulously cleaned of any residual muscle tissue. The free ends of the tendon were then sutured using a continuous whipstitch technique, extending 4 to 5 cm from each end, employing No. 2 polybraided nonabsorbable suture (Ethibond). The prepared graft was quadrupled and threaded through the loop of the Endobutton, after which its diameter was accurately determined using a graft sizer. Once measured, the graft was stored in sterile, moist gauze to maintain hydration until implantation.

Tunnel Preparation and Graft Fixation

Femoral Tunnel:

With the knee in 120° flexion, the femoral footprint of the ACL was identified and drilled using a femoral offset aimer. A guide pin was advanced through the lateral femoral condyle, and the tunnel was reamed corresponding to the graft diameter.

Tibial Tunnel:

With the knee flexed to 70–90°, the tibial guide was set to 50–55°, and a guide pin was inserted just medial to the ACL tibial footprint. The tibial tunnel was drilled using a cannulated reamer of corresponding size.

Graft Passage and Fixation:

The graft with an attached endobutton was passed through the tibial and femoral tunnels. Once the endobutton was flipped and secured on the lateral femoral cortex, the tibial end was fixed using an appropriately sized titanium interference screw under arthroscopic visualization. Cyclical knee flexion and extension were performed to confirm stable fixation and rule out impingement.

Postoperative Protocol and Assessment

All patients underwent a standardized postoperative rehabilitation protocol emphasizing early mobilization and progressive strengthening. Functional outcomes were evaluated at 1, 3, 6, and 9 months using the Lysholm Knee Score and the International Knee Documentation Committee (IKDC) scoring system.

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using SPSS version 22.0. Categorical variables were expressed as frequencies and percentages. Continuous variables were reported as mean ± standard deviation. The Kolmogorov–Smirnov and Shapiro–Wilk tests were applied to assess data normality. Between-group comparisons for continuous variables were performed using the independent t-test. Chi-square test was used for categorical data. A p-value of <0.05 was considered statistically significant.

A total of 60 participants were enrolled in the study. The age range of participants was 19 to 49 years, with an overall mean age of 32.82 years, with Group ST averaging 33.4 years and Group PLT averaging 32.3 years, indicating comparable age distribution across both groups. The age distribution reveals that in both Group ST and Group PLT; the majority of participants (46.7%) were aged ≤30 years. The 31–40 years category was more represented in Group PLT (33.3%) than in Group ST (26.6%). Participants aged >40 years were fewer in both groups, especially in Group PLT (20%) compared to Group ST (26.6%), indicating a younger age profile across both study arms.

Males predominated in both groups, comprising 86.7% in Group ST and 93.33% in Group PLT. This male predominance reflects the known higher incidence of ACL injuries among males, possibly due to higher participation in high-risk physical and athletic activities.

In Group ST, the right knee was more frequently affected (66.67%), whereas in Group PLT, the left knee was more commonly involved (66.67%). This variation may be incidental, as no specific laterality dominance has been conclusively associated with ACL injury risk. Posterior horn medial meniscus tear was the most common associated injury in both groups, affecting 13.33% of patients in Group ST and 10.00% in Group PLT. This finding is consistent with existing literature, where meniscal injuries frequently co-occur with ACL tears due to similar injury mechanisms, particularly rotational or valgus stress on the knee joint. Overall, both groups were comparable in terms of demographic distribution and associated intra-articular injuries, ensuring a balanced comparison for evaluating the functional outcomes of the two graft types used in ACL reconstruction.

Table 1: Demographic and Clinical Profile of Study Participants

Postoperative functional outcomes, as measured by the Lysholm Knee Scoring System, indicated excellent results in 60% of patients in Group ST and 73.33% in Group PLT. The remaining patients in each group (40% in Group ST and 26.67% in Group PLT) demonstrated good outcomes. The mean Lysholm score postoperatively was 90.6 ± 3.18 in Group ST and 92.2 ± 2.65 in Group PLT. Statistical analysis revealed no significant difference in mean Lysholm scores between the two groups (p = 0.439), suggesting comparable functional recovery.

According to the International Knee Documentation Committee (IKDC) grading, 66.67% of patients in Group ST were classified as Grade A, while 33.33% fell under Grade B. In Group PLT, 73.33% were graded as A and 26.67% as B. The difference in IKDC grading distribution between the two groups was not statistically significant (p = 0.690), indicating similar postoperative knee function.

Assessment of anterior knee laxity using the Lachman test showed that 66.67% of patients in Group ST had negative results, while 33.33% showed a 1+ grade. In Group PLT, 73.33% tested negative and 26.67% had 1+ laxity. The distribution of postoperative Lachman grades was not significantly different between the groups (p = 0.690), demonstrating effective graft stability in both.

Table 2: Postoperative Functional Outcome Comparison Between Groups

Postoperative Complications: In the semitendinosus graft group (Group ST), the most frequently reported complication was anterior knee pain, observed in 8 patients (26.7%). Quadriceps hypotrophy was present in 6 patients (20%), while graft site infection occurred in 2 patients (6.7%). Paraesthesia was reported in 2 patients (6.7%), likely attributable to injury of the inferior genicular nerve during graft harvesting. Additionally, one patient in this group experienced a 10° restriction in knee flexion (range: 0°–80°), which was associated with poor adherence to the postoperative rehabilitation protocol. In contrast, the peroneus longus tendon graft group (Group PLT) showed fewer overall complications. Quadriceps hypotrophy was noted in 4 patients (13.3%), anterior knee pain in 4 patients (13.3%), and graft site infection in 2 patients (6.7%). Notably, no cases of paraesthesia were observed in this group, suggesting a potential neurological advantage of the peroneus longus harvesting approach over the semitendinosus route.

Anterior cruciate ligament (ACL) injuries are a prevalent orthopedic concern, particularly among young, active individuals. These injuries often necessitate surgical reconstruction to restore knee stability, function, and long-term joint integrity. In the present prospective study, a comparison was made between semitendinosus tendon (Group ST) and peroneus longus tendon (Group PLT) autografts in arthroscopic ACL reconstruction, focusing on postoperative functional outcomes and complication profiles in a cohort of 60 patients.

The age of participants ranged from 19 to 49 years, with an overall mean age of 32.82 years; Group ST had a mean age of 33.4 years and Group PLT 32.3 years, indicating a comparable age distribution. Notably, both groups had the highest proportion of participants aged ≤30 years (46.7%). The 31–40 years group was more represented in Group PLT (33.3%) than in Group ST (26.6%), while participants aged >40 years were fewer overall, with Group ST accounting for 26.6% and Group PLT 20%. This pattern reflects a predominantly younger age profile across both groups, likely due to increased physical activity and risk exposure in younger individuals, predisposing them to anterior cruciate ligament (ACL) injuries at an earlier age. A strong male predominance was observed in both groups—86.7% in Group ST and 93.33% in Group PLT—mirroring trends reported in prior literature. This aligns with findings by Ambulgekar RK et al. (2023) [1], who reported mean ages of 34.67 ± 8.54 and 33.13 ± 8.59 years in ST and PLT groups, respectively, with a dominant male demographic. Similar demographic patterns have been reported by Sabat D et al. (2016) [12], who recorded a mean age of 34.2 years with 91.5% male patients, and by Seitz H et al. [13], who documented 76.6% male predominance in their series. The high male representation may be attributed to increased exposure to high-velocity trauma, such as road traffic accidents and contact sports, both of which are prominent contributors to ACL injuries in developing regions.

Further supporting this demographic trend, Nair NMS et al. (2024) [14] conducted a prospective study on 120 patients undergoing ACL reconstruction with peroneus longus autografts and found the majority (36%) were aged 20–25 years, with a mean age of 27.1 ± 6.85 years and 88% male representation. The consistency of these findings across multiple studies strengthens the generalizability of data regarding graft selection and surgical outcomes in similar patient populations.

In the present study, associated intra-articular pathology—specifically posterior horn medial meniscus tears—was documented in 13.33% of patients in Group ST and 10% in Group PLT. These observations are consistent with previous reports highlighting the frequent co-occurrence of meniscal injuries with ACL tears, particularly due to shared mechanisms involving rotational or valgus forces. Prior studies such as those by Sabat D et al. (2016) [12] and Seitz H et al. [13] have also emphasized the dominant role of road traffic accidents in causing ligamentous knee trauma, including both ACL and PCL injuries. Ambulgekar RK et al. (2023) [1] similarly identified road traffic accidents as the most prevalent mode of injury in their ACL reconstruction cohort. This trend was further validated by Nair NMS et al. (2024) [14], who reported that 55% of ACL injuries in their series were attributable to road traffic accidents.

Collectively, the demographic and injury pattern findings of the present study are in concordance with existing literature, supporting the external validity of the results and underscoring the utility of both semitendinosus and peroneus longus tendons as viable graft choices in ACL reconstruction, especially within trauma-dominant clinical settings.

Postoperative functional assessment using the Lysholm Knee Score revealed that 60% of patients in the ST group and 73.33% in the PLT group achieved excellent outcomes. The mean Lysholm score was slightly higher in the PLT group (92.2 ± 2.65) compared to the ST group (90.6 ± 3.18), though the difference was not statistically significant (p = 0.439). These results align with findings from Ambulgekar RK et al. (2023) [1], who reported identical Lysholm outcomes in their comparative analysis. Similar results were documented by Sharma D et al. (2019) [15], who reported excellent Lysholm scores in 80% of PLT patients, and by Sabat D et al. (2016) [12], who observed high Lysholm scores across different graft and surgical techniques.

Additional support comes from Shair NA et al. (2023) [16] and Nair NMS et al. (2024) [14], both of whom reported significant postoperative improvements in Lysholm and IKDC scores following PLT-based reconstructions. These findings reinforce the growing evidence of PLT’s suitability as a robust autograft with high functional efficacy.

IKDC grading in our study further supported these outcomes. Grade A (normal) function was seen in 66.67% of ST patients and 73.33% of PLT patients, while the rest showed near-normal (Grade B) outcomes. The difference was not statistically significant (p = 0.690), echoing the observations of Ambulgekar RK et al. (2023) [1] and Kumar VK et al. (2020) [17]. Likewise, Vijay VK et al. (2024) [18] and Nair NMS et al. (2024) [14] found comparable IKDC scores between PLT and hamstring grafts, indicating functional equivalence.

Anterior knee laxity, measured using the Lachman test, was negative in 66.67% of ST patients and 73.33% of PLT patients, with the remainder exhibiting 1+ laxity. This distribution mirrors that reported by Ambulgekar RK et al., where approximately 70% of patients had negative Lachman results and 30% had mild laxity postoperatively. Comparable findings were also seen in studies by Kim DK et al. (2018) [19] and Rhatomy S et al. (2019) [20], confirming the biomechanical reliability of both grafts in maintaining postoperative knee stability

.

Postoperative complications were generally mild in both groups. Anterior knee pain was more prevalent in the ST group (26.7%) than in the PLT group (13.3%), potentially attributable to hamstring harvest site morbidity. Quadriceps hypotrophy was also slightly more frequent in the ST group (20% vs. 13.3%). Notably, paraesthesia occurred in 6.7% of ST patients and was absent in the PLT group, suggesting a potential neurological advantage of the peroneus longus harvesting technique.

Superficial wound infection occurred at an equal rate in both groups (6.7%) and was effectively managed with antibiotics. No implant failures or major complications were observed in either cohort. These findings are consistent with earlier reports by Rhatomy S et al. (2019) [20], Williams III et al. [21], and Ambulgekar RK et al. (2023) [1], all of whom noted low complication rates and effective management of donor site infections.

Moreover, prior studies by Rahnemai-Azar AA et al. (2016) [22] and Xu H et al. (2016) [23] have documented similarly low implant-related complications. Stucken C et al. (2013) [24] emphasized the importance of early detection of postoperative infections to prevent long-term sequelae such as cartilage damage and arthrofibrosis—a principle that was successfully upheld in our clinical setting.

Overall, our study reaffirms that both semitendinosus and peroneus longus autografts are reliable options for ACL reconstruction. However, the PLT graft demonstrates a slightly better clinical profile in terms of functional outcomes and complication rates. This aligns with the growing body of literature supporting PLT as a safe and effective autograft, particularly in settings where hamstring grafts may be contraindicated or undesirable.

This study was limited by a relatively small sample size and short-term follow-up duration. Additionally, objective assessment tools like instrumented laxity testing were not employed.

Arthroscopy-assisted anterior cruciate ligament (ACL) reconstruction using either semitendinosus or peroneus longus autografts yields comparable functional outcomes, with both techniques providing satisfactory knee stability, reduced morbidity, and early rehabilitation potential. The peroneus longus tendon, however, offers additional advantages such as ease of harvest, consistent graft diameter, lower donor site morbidity, and a more cosmetically favorable scar, making it particularly appealing for athletes. Given its equivalent functional performance and added benefits, the peroneus longus tendon may be considered a reliable and encouraging alternative to the hamstring tendon in routine clinical practice for single-bundle ACL reconstruction.

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