Background

Recent comparative studies suggest that the peroneus longus tendon (PLT) may be a good alternative autograft in anterior cruciate ligament (ACL) reconstruction in terms of strength, efficacy, and safety. However, the presence of several donor ankle morbidities observed postoperatively suggests a possible gap in the operative technique described in current literature. The aim of this study is to describe a surgical technique in harvesting the PLT for arthroscopic reconstruction of the posterior cruciate ligament (PCL) in patients with combined ACL-PCL tears, thereby decreasing, if not eliminating, the postoperative outcome of donor ankle weakness.

Methods

In this case series, four patients diagnosed with combined ACL-PCL tears undergo simultaneous arthroscopic reconstruction of the ACL and PCL using the ipsilateral hamstring and peroneus longus tendon (PLT) as autografts respectively. After harvesting the PLT, the remaining distal stump of the tendon was sutured on to the peroneus brevis using simple interrupted technique. Functional Foot Index (FFI) was utilised to measure clinical functional outcome of the donor ankle, whereas Knee Injury and Osteoarthritis Outcome Score (KOOS) was utilized to measure clinical functional outcome of the injured knee. Manual Muscle Testing (MMT) was used to document motor strength of the donor ankle, and special tests of the knee were performed to assess stability of the injured knee.

Results

With the longest follow-up period of 3 years, significant and continuous improvements were noted in clinical functional outcomes of the donor ankle and injured knee in all patients who underwent the surgical procedure. Physical examination findings reveal no weakness in first ray plantarflexion and foot eversion of the donor ankle as early as 3 months in the postoperative period. Previously positive findings in the special tests performed on the knee, suggesting the presence of a multi-ligamentous injury, reveal negative findings immediately intraoperatively, as soon as the autografts are secured.

Conclusion

Suturing the distal stump of the remaining PLT to peroneus brevis is a novel and crucial step in preventing donor ankle morbidity after harvesting the PLT for PCL reconstruction in combined ACL-PCL tears. Significant improvements in clinical functional outcome, and preservation of preoperative motor strength of the donor ankle suggest that donor ankle morbidity is prevented. Furthermore, significant improvements in clinical functional outcome and stability of the injured knee makes PLT a suitable graft for PCL in simultaneous ACL-PCL arthroscopic reconstruction.