Harvesting of Peroneus Longus Tendon Autograft

Summary

This article provides a method for safely harvesting the full-thickness peroneus longus tendon autograft. It outlines critical steps, modifications, and troubleshooting for the procedure.

Abstract

Autografts are always used in anterior cruciate ligament (ACL) reconstruction. Traditional sources, such as hamstring tendons, bone-patellar tendon-bone, and quadriceps tendon, are popular choices but may result in muscle imbalances and dynamic differences in knee kinematics. The peroneus longus tendon (PLT) has emerged as an alternative autograft for ACL reconstruction, offering comparable functional outcomes and avoiding interference with the flexor-extensor complexes of the knee. However, concerns about donor site paresthesia and ankle dysfunction have been raised in PLT harvesting. This article presents a detailed protocol for safely and effectively obtaining this autograft. The protocol emphasizes critical steps, modifications, and potential troubleshooting methods. In this study, we assessed functional scores, donor paresthesia, and other complications in 20 patients six months after PLT harvesting. Our findings indicate that this protocol for PLT acquisition did not result in significant complications. Therefore, we confirm the effectiveness of this protocol and offer guidance on essential preoperative preparations and surgical techniques.

Introduction

Anterior cruciate ligament (ACL) injuries, often incurred by high-level athletes, pose a substantial challenge to those wishing to return to sports¹. ACL reconstruction using autografts is the prevailing treatment approach in such cases, with popular graft choices worldwide encompassing hamstring tendons, bone-patellar tendon-bone, and quadriceps tendon^2,3,4. While these autograft sources offer efficacy, they share a commonality in being integral components of the knee's flexor-extensor complexes. This interconnectedness has raised concerns regarding muscle imbalances between the quadriceps and hamstrings, and decreased thigh circumference, leading to dynamic differences in knee kinematics post-autograft harvesting. These issues significantly affect an athlete's return to sports^5,6,7.

Recent exploration has spotlighted the peroneus longus tendon (PLT) as a promising alternative autograft for ACL reconstruction, showcasing functional outcomes compared with established autografts⁸. A distinctive advantage of the PLT is its extra knee location, sidestepping the complexities posed by traditional autografts. However, this innovation has unique challenges, notably concerning donor site paresthesia^9,10. Reports indicate that patients who undergo PLT autograft harvesting may experience ankle paresthesia, albeit at varying rates, ranging from 0% to 14.1%, and sometimes as low as 4.3% based on a meta-analysis^8,10,11. The etiology of these paresthesias has remained controversial, with hypotheses suggesting peroneal nerve or sural nerve involvement, or both¹². These outcome discrepancies can be attributed to differences in incision locations and harvesting techniques. The sural nerve, which courses superficially in the posterior leg, provides sensation to the lateral ankle, while the peroneal nerve innervates the peroneus longus and brevis muscles and offers sensation to the lateral aspect of the dorsal foot and the lower leg. Consequently, paresthesia may originate from injury to one or both nerves. Therefore, considering the complications in harvesting PLT, a detailed protocol must be urgently standardized.

Here we present a standardized protocol for harvesting the full-thickness PLT autograft, aiming to guide clinicians in minimizing complications.

Protocol

The protocol was approved by the human ethics committee of the third Xiangya Hospital of Central South University and informed consent was obtained from the patient prior to making the video for educational purposes.

1. Inclusion/Exclusion criteria

1. Inclusion criteria:
   1. Confirm that the anterior cruciate ligament (ACL) is completely torn and that all patients are unilateral.
   2. Perform single-beam reconstruction as a type of operation.
   3. Utilize the ideal positioning method for tunnel positioning on the femur side.
   4. Employ the end button plate for fixation on the femur side and a squeeze screw for fixation on the tibia side.
   5. Ensure all operations are conducted by the same surgeon.
   6. Confirm that the patient is willing to cooperate with follow-up and possesses complete clinical data.
2. Exclusion criteria
   1. Exclude patients who have lost follow-up or dropped out of the study.
   2. Exclude patients with other ligament injuries or meniscus sutures.
   3. Exclude patients with related foot and ankle injury deformities or other relevant histories.
   4. Exclude patients diagnosed with peroneal long tendon disease.

2. Preoperative preparation

1. Confirm patient identity and obtain informed consent. Make a proper surgical site marking.
2. Administer anesthesia according to the patient's needs and medical history.
3. Use ultrasound to locate the PLT graft area above the posterior lateral malleolus and accurately predict the diameter of the PLT autograft by measuring the cross-sectional area at the proximal end of the incision 1 cm away.
4. Position the patient supine or lateral decubitus with the operative limb appropriately exposed, disinfected, and cover using a sterile drape.

3. Incision location and tendon Isolation

1. Make a 1-2 cm longitudinal incision 1 cm posterior and 2 cm proximal to the midpoint of the lateral malleolus using a scalpel (Figure 1).
2. Delicately dissect the subcutaneous tissue with tissue scissors, taking care to identify and preserve the sural nerve¹³.
3. Expose and isolate the full-thickness PLT using forceps. Confirm the absence of fibrous connections between the PLT and nearby essential ligament structures. Approximately less than 5 min of surgical time is required to harvest the PLT, which may be cost-effective compared to hamstring tendon harvesting.
4. Do not harvest the nearby peroneus brevis tendon (PBT), which is more anterior and deeper relative to the location of PLT.

4. Harvesting the tendon

1. Elevate the PLT and stitch the proximal part of the PLT via a whip-stitch style for subsequent autograft harvest and mark the distal portion of the PLT with another kind of sutures (Figure 2).
2. Place the ankle at plantarflexion and the knee at 90° or full extension.
3. Transversely section the PLT with tissue scissors.
4. Suture the distal portion of PLT to the PBT with a suture (Figure 3).
5. Harvest the full-thickness PLT with a standard closed, blunt-ended tendon stripper. The stripper is also kept parallel and superficial to the fibula to avoid injury to the superficial peroneal nerve and stopped 5 cm below the fibular head to prevent injury to the deep peroneal nerve (Figure 4).
6. Close the surgical incision in layers using sutures, ensuring hemostasis and proper skin edge alignment.
7. Apply sterile dressing over the wound and provide a sterile bandage to protect the surgical site as needed.

5. Postoperative care

1. Transfer the patient to the recovery area, monitoring vital signs and implementing appropriate pain management.
2. Educate the patient on postoperative care instructions, including immobilization and rehabilitation guidelines.
3. Schedule follow-up appointments for wound assessment, suture removal, and rehabilitation progression.

Results

Our previous successful experiments demonstrated this protocol's optimal graft harvest, minimal complications, and positive patient outcomes. Preoperative measurements of the PLT cross-sectional area using high-resolution ultrasound, particularly 1 cm proximal to the distal harvest incision, accurately predict the intraoperative diameter of the PLT graft (Figure 5)¹⁴. This consistency confirms the method's reliability in selecting the appropriate graft size for ligame...

Discussion

Choosing the right graft is critical for the success of any ligament reconstruction surgery. The peroneus longus tendon (PLT) offers significant advantages over other graft options, such as semitendinosus tendons, primarily due to it's generally larger average diameter, which can provide greater strength and stability⁸. In our study, PLT grafts typically achieved a diameter of 8-10 mm after being doubled and braided¹⁴. Additionally, using PLT does not disrupt the knee j...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Ultrasound	GE LOGIQ, USA		12-13 MHz linear array transducer
General surgical instruments	Smtih & Nephew, USA
Tendon Stripper	Smtih & Nephew, USA		Closed blunt-ended tendon stripper