Ligament and tendon injuries constitute a major chunk of sports medicine surgeries [1]. Among them, anterior cruciate ligament (ACL) injuries have a high incidence, and most of its patients require repair or reconstruction. These injuries in a non-athletic patient, depending on the grade and willingness of the patient to make lifestyle changes and to avoid activities that can cause recurrent instabilities, do not always require reconstruction.

Moreover, the knees of these patients are not subjected to stress and tension unlike an athletic patient. ACL is the major stabilizing ligament of knee as it prevents anterior translation of the tibia

over the femur. It also contributes to the dynamic stability of the knee, so it is an important structure for maintaining normal knee movements [2]. If ACL injuries are left untreated, they can further result in meniscal injuries and ultimately degenerative arthritis of knee joint [3]. ACL injuries can be treated both conservatively with a knee brace and physical therapy and operatively by repair (isolated or augmented) or reconstruction (allograft or autograft) of the ligament.

For the decision to be made on this aspect, there are several criteria to be considered like activity level of the patient, comorbid injury, age group, and functional demand of the patient [4]. When reconstruction of ACL is indicated, the option of both allografts and autografts can be considered. Allograft has a drawback of being higher in cost, delayed incorporation, higher chances of disease transmission, and immunological reactions. The most commonly used autografts are bone patellar tendon bone (BPTB) or double-looped/quadruple-looped semitendinosus or gracilis autograft (hamstring autograft). Other options include fascia lata, iliotibial band, and quadriceps tendon with or without bone [5]. Anterior cruciate ligament reconstruction (ACLR)is among the most common procedures in orthopaedic surgery, yielding good-to-excellent outcomes and patient satisfaction [6-8].

Although extensively investigated, several technical issues remain under discussion, including tunnel placement, number of bundles, fixation and graft selection [9-11]. The patellar tendon (PT) has been considered the ‘gold standard’ graft in primary ACLR, especially in young and active patients [12].

The aim of the present study was to assess the functional outcomes of arthroscopic reconstruction of Anterior Cruciate ligament using Peroneus longus tendon graft compared to hamstring tendon graft among patients presenting with ACL injury.

The present study was conducted on the patients who presented to Department of Orthopaedics, Kanyakumari Government Medical College Hospital, Asaripallam with complaints of injury to knee with clinical and radiological evidence of ACL tear and requiring reconstruction surgery for management of the condition. Hence the final sample size of 20 (10 in each group) was included in the study.

Inclusion Criteria:

• Patients with clinically Lachman test, anterior drawers test or MRI positive for ACL rupture were included in our study.
• All cases with anterior cruciate ligament injuries irrespective of the mode of injury/duration/mechanism of injury/associated injuries of menisci.

Exclusion Criteria:

• Patients with bony ACL avulsion or other associated fractures were excluded from our study.
• Cases with multiple ligament injuries of the knee, Cases with bilateral ACL injuries and revision ACL reconstructions were excluded from the study.

SURGICAL PROCEDURE

POSITION: Supine under Tourniquet Control.

PERONEUS LONGUS GRAFT:

Peroneus longus tendon graft is harvested with a longitudinal skin incision at 2 to 3 cm (2 finger-breadths) above and 1 cm (1 finger-breadth) behind the lateral malleolus, followed by superficial fascia incision in line with skin incision. The peroneus longus and peroneus brevis tendons were then identified. The tendon division location was marked at 2 to 3 cm above the level of the lateral malleolus. After that, an end-to-side suture was performed between the distal part of the peroneus longus tendon and peroneus brevis tendon. The peroneus longus tendon was stripped proximally with a tendon stripper to at least 5 cm from the fibular head to prevent peroneal nerve injury. Graft preparation was performed with a standard procedure to obtain the suitable graft size.

STUDY PROCEDURE

The study was carried out after obtaining Ethical Committee Approval. Patients who fulfilled the eligibility criteria was included in the study and baseline information was collected. Written informed consent was obtained from all the participants. All eligible patients were subjected to basic investigations including Blood tests and radiological examination using X-ray and MRI. Baseline information was collected using the interview schedule. Patients were randomized into two groups-either Peroneus longus tendon graft or Hamstring tendon graft group. Randomization was performed by an independent statistician, not involved in the study. The randomization sequence was concealed by Serially Numbered Opaque Sealed Envelopes (SNOSE). As and when eligible patients were met, an envelope was opened, and the intervention group was assigned accordingly. The patients were followed up immediately during the post-op period and also at 2 weeks, 6 weeks, 3 months, and 6 months following surgery. Endline information was also collected during all these time points.

OUTCOME ASSESSMENT

The following outcomes were assessed immediate post-operative period, 2 weeks and 6 weeks following the surgery:

• Lysholm score.
• International Knee Documentation committee (IKDC) scores.
• Donor-site pain (VAS score).

In addition to the above outcomes, Lachman test, pivot-shift test, and graft failure were assessed at 3 months and 6 months following surgery. Pre-operative and post-operative subjective pain measured with VAS (Visual analogue scale) ranging from 0 indicating no pain and 10 indicating extremely severe pain.

STATISTICAL ANALYSIS

The data was entered using Excel 2011 (Microsoft Corp) and statistical analysis performed using SPSS software version 19. The normal distribution of the measured variables was verified using the Shapiro-Wilk test, and the homogeneity of variances were verified using Levene’s test to ensure that assumptions had been met for parametric testing. The significance threshold was set at P-value of 0.05. The descriptive analysis was performed and reported as mean (with SD), or median (with IQR) values. A comparative analysis was performed using unpaired Student t test for continuous variables or chi-square test for nominal and ordinal data.

Table 1: Demographic data

More than half (60) of the study participants were in the age category between 17 and 25 years. Forty percentage of the patients were in age group of 26 to 42 years. The study population comprised of 95% males and 1% female. Most of the patients were students followed by manual labour. The mode of injury was RTA (50%) and sports injury (50%). 65% had left side injury.

Table 2: Arthroscopy Findings4

The most common arthroscopic findings were complete ACL tear (50%), Complete ACL tear with Bucket handle tear medial meniscus (10%), Complete Acl tear, chondromalacia along with Bucket handle tear medial meniscus (15%), Complete Acl tear, chondromalacia, Posterior horn medial meniscus tear (10%), Complete ACL tear, Gr 1 tear posterior horn of medial meniscus (5%) and Complete ACL tear, Gr 11 tear posterior horn of medial meniscus (5%).

Table 3: Functional Outcome Scoring

Functional outcome analysis was done using Tegner Lysholm Score and IKDC score done at 2 weeks, 6 weeks, 3 months and 6 months.

Table 4: Tegner Lysholm score between study groups

The mean Tegner Lysholm score was compared at 2 weeks, 6 weeks, 3 months and 6 months between the two groups which showed that there is no significant association between the two groups. Tegner Lysholm score was found to be improving from the 2 week to 6 months with the mean value ranging between 59 to 93 in the hamstring group whereas in the peroneous longus group the mean value ranged between 61 and 94. In both the groups it was found that the score was improving from the time of surgery but the difference between the two study groups was found to be statistically insignificant.

Table 5: IKDC score between study groups

IKDC score was found to be improving from the 2 week to 6 months with the mean value ranging between 41 to 86 in the hamstring group whereas in the peroneus longus group the mean value ranged between 40 and 85. In both the groups, it was found that the score was improving from the time of surgery. However, the change in the score was found to be insignificant among the two study groups.

Table 6: Donor Site Pain

The mean donor site pain score was compared at 2 weeks, 6 weeks, 3 months and 6 months between the two study groups. In Hamstring and peroneus group, at 2 weeks the mean pain score was 7 and 7.2, at 6 weeks it was 4.2 and 3.7, at 3 months the score was further reduced to 1 and 0.9 and the end of 6 months the score was found to be much reduced to less than one.

Table 7: Lachman Test

The Lachman test grade was compared between the study groups which showed that 16 study participants were in the Lachman Grade of 2A at 3 months and 3 people in 1A and 1 person in grade 1b and there was significant association between the two groups.

Table 8: Pivot shift grade at 3 months and 6 months follow-up

The pivot shift grade was compared between the study groups showed that 5 participants were in 0 grade and 15 were in grade 1 at 3 months with significant association between the two groups. The pivot shift grade was compared between the study groups at 6 months follow-up showed that 15 participants were in 0 grade and 5 were in grade 1 at 6 months with significant association between the two groups.

The anterior cruciate ligament (ACL) is one of the most frequently injured knee joint structures, with an estimated incidence of 1.5% to 1.7% primary ACL cases per year in the general population [13, 14]. Surgical reconstruction using a commonly originated graft from the patient's muscle (autograft) has become a widely performed procedure in management for an ACL injury to maintain the functionality and stability of the knee [15].

The current study population was 95% males and 1% female. The mean (SD) age of the study participants in years was 24.5(6.5). More than half (60) of the study participants were in the age category between 17 and 25 years. Forty percentage of the patients were in age group of 26 to 42 years. The mode of injury in our study include RTA (50%) and sport injury (50%). The median (Interquartile range) time duration in days from the time of injury to presenting to the clinician among the study population was 300(60-360). The mean (SD) of the time since last follow up of the study population was 11.4(4.2) The most common arthroscopic findings were complete ACL tear (50%), Complete ACL tear with Bucket handle tear medial meniscus(10%), Complete Acl tear, chondromalacia along with Bucket handle tear medial meniscus(15%), Complete Acl tear, chondromalacia, Posterior horn medial meniscus tear (10%), Complete ACL tear, Gr 1 tear posterior horn of medial meniscus (5%) and Complete ACL tear, Gr 11 tear posterior horn of medial meniscus (5%). Anterior cruciate ligament reconstruction (ACLR) is the most common surgery to restore the injured ACL using the placement of graft material. The choice of graft is the most crucial operative plan consideration. The appropriate graft helps to prevent re-injury or re-rupture incidents and provides optimal knee stability. Mohtadi et al. [16] reported that HT graft and bone patella tendon bone (BPTB) are related to post-operative complications, including anterior knee pain and stiffness.

The mean Tegner Lysholm score was compared at 2 weeks, 6 weeks, 3 months and 6 months between the two groups which showed that there is no significant association between the two groups. The mean IKDC score was also compared at 2 weeks, 6 weeks, 3 months and 6 months between the two groups which showed that there is no significant association between the two groups. However, there was significant improvement in both the functional scores in the peroneus longus group as well as the hamstring group. This is suggestive of the fact that the functional outcome post ACL reconstruction with peroneus longus graft can be as par with the conventional hamstring autograft. Comparative studies on the use of HT and PLT grafts showed no significant differences between the pre- and 1-year post-surgery, based on the IKDC, modified Cincinnati, and Lysholm Knee Scoring Scale. The PLT graft was considered more superior because it provides larger graft diameter and less thigh hypotrophy with excellent ankle function based on AOFAS and Foot and Ankle Disability Index (FADI) [17, 18]. Bi et al. [19] compared the use of single-bundle anterior half of PLT vs. semitendinosus tendon. At the 2-year follow-up, the study found no differences between both groups in the VAS scale, IKDC score, pivot shift test, and KT-1000. Besides, the AOFAS score in the PLT group was more excellent than the semitendinosus tendon group. This finding concluded that PLT graft provides greater strength and relatively safe for reconstruction.

Rhatomy S et al. [20] in their study found that there were no significant differences between the pre- and 1-year postoperative scores among the two groups in the IKDC (n.s), modified Cincinnati (n.s), and Lysholm (n.s). The mean AOFAS was 98.3 ± 4.2 and for the FADI 99± 3.4 for peroneus longus group, with a significant reduction in thigh circumference among hamstring group (p = 0.002) participants. The mean donor site pain score was compared at 2 weeks, 6 weeks, 3 months and 6 months between the two groups which showed that there was progressive improvement in the pain score but no significant association between the score in both the groups.

Knee laxity was evaluated using Lachman test and Pivot shift test at 3 months and 6 months post-operative period. No significant difference was found between both the groups. There was improvement in knee stability at 3 months and 6 months follow-up in both the study groups. The stability with peroneus longus graft was comparable to the stability of the hamstring group. Kumar S et al. [21] study showed that International Knee Documentation Committee (IKDC) scoring was used to assess the post-operative knee functions. The study included 25 patients with the preserved the ankle functions at the donor site and confirmed by the grading the power of foot eversion. Post operatively knee function (IKDC scoring) were found to be normal in 95%. The current study did not show any significant improvement in scores which could be due to less follow up period in the postoperative period. Regardless of all the advantages of PLT grafts in ACL reconstruction, the graft preference was decided based on various clinical considerations by the surgeons. In achieving an excellent result, the consideration of the appropriate graft usage depends on many factors, including the associated meniscal and ligament lesions, high or low demand patient's activities, medical condition or comorbidities, pre-surgical status, patient decision, and the post-operative rehabilitation protocol.²²

In conclusion, there is no significant difference in functional outcome evaluation in terms of clinical testing and post-operative knee outcome scoring (IKDC score and Tegner-Lysholm score) on comparing Peroneus longus graft with Hamstring graft. Peroneus longus graft had a larger graft diameter, less post-op anterior knee and no documented ankle weakness. Peroneus longus graft can be considered a robust graft with functional outcomes comparable to the hamstring graft. It can be considered as an alternative graft for ACL reconstruction with no risk of complications. It can also be used as an adjunct in multi-ligamentous injuries. However its role as a primary graft needs further evaluation in terms of graft characteristics and biomechanical properties.

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