Name: Harvesting of Peroneus Longus Tendon Autograft (Video) | JoVE Journal
Uploaded: 2025-09-02T13:30:00.000+00:00
Duration: 4 min 3 s
Description: Learn a reliable method for harvesting the peroneus longus tendon autograft using ultrasound localization and closed tendon stripper techniques. This protocol minimizes complications and enhances outcomes in orthopedic surgeries.

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5 minutes

This work was financially supported by the Wisdom Accumulation and Talent Cultivation Project of the Third Xiangya Hospital of Central South University (YX202209).

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
<ol>
	<li>Inclusion criteria:
	<ol>
		<li>Confirm that the anterior cruciate ligament (ACL) is completely torn and that all patients are unilateral.</li>
		<li>Perform single-beam reconstruction as a type of operation.</li>
		<li>Utilize the ideal positioning method for tunnel positioning on the femur side.</li>
		<li>Employ the end button plate for fixation on the femur side and a squeeze screw for fixation on the tibia side.</li>
		<li>Ensure all operations are conducted by the same surgeon.</li>
		<li>Confirm that the patient is willing to cooperate with follow-up and possesses complete clinical data.</li>
	</ol>
	</li>
	<li>Exclusion criteria
	<ol>
		<li>Exclude patients who have lost follow-up or dropped out of the study.</li>
		<li>Exclude patients with other ligament injuries or meniscus sutures.</li>
		<li>Exclude patients with related foot and ankle injury deformities or other relevant histories.</li>
		<li>Exclude patients diagnosed with peroneal long tendon disease.</li>
	</ol>
	</li>
</ol>
2. Preoperative preparation
<ol>
	<li>Confirm patient identity and obtain informed consent. Make a proper surgical site marking.</li>
	<li>Administer anesthesia according to the patient&#39;s needs and medical history.</li>
	<li>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.</li>
	<li>Position the patient supine or lateral decubitus with the operative limb appropriately exposed, disinfected, and cover using a sterile drape.</li>
</ol>
3. Incision location and tendon Isolation
<ol>
	<li>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).</li>
	<li>Delicately dissect the subcutaneous tissue with tissue scissors, taking care to identify and preserve the sural nerve13.</li>
	<li>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.</li>
	<li>Do not harvest the nearby peroneus brevis tendon (PBT), which is more anterior and deeper relative to the location of PLT.</li>
</ol>
4. Harvesting the tendon
<ol>
	<li>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).</li>
	<li>Place the ankle at plantarflexion and the knee at 90&#176; or full extension.</li>
	<li>Transversely section the PLT with tissue scissors.</li>
	<li>Suture the distal portion of PLT to the PBT with a suture (Figure 3).</li>
	<li>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).</li>
	<li>Close the surgical incision in layers using sutures, ensuring hemostasis and proper skin edge alignment.</li>
	<li>Apply sterile dressing over the wound and provide a sterile bandage to protect the surgical site as needed.</li>
</ol>
5. Postoperative care
<ol>
	<li>Transfer the patient to the recovery area, monitoring vital signs and implementing appropriate pain management.</li>
	<li>Educate the patient on postoperative care instructions, including immobilization and rehabilitation guidelines.</li>
	<li>Schedule follow-up appointments for wound assessment, suture removal, and rehabilitation progression.</li>
</ol>

<ol><li>Musahl, V., Karlsson, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Anterior+cruciate+ligament+tear%5BTitle%5D)+AND+%22N+Engl+J+Med%22%5BJournal%5D)">Anterior cruciate ligament tear.</a> N Engl J Med. 380 (24), 2341-2348 (2019).</li>
<li>Shelton, W. R., Fagan, B. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Autografts+are+commonly+used+in+anterior+cruciate+ligament+reconstruction%5BTitle%5D)+AND+%22J+Am+Acad+Orthop+Surg%22%5BJournal%5D)">Autografts are commonly used in anterior cruciate ligament reconstruction.</a> J Am Acad Orthop Surg. 19 (5), 259-264 (2011).</li>
<li>Mouarbes, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Anterior+cruciate+ligament+reconstruction%3A+a+systematic+review+and+meta-analysis+of+outcomes+for+quadriceps+tendon+autograft+versus+bone-patellar+tendon-bone+and+hamstring-tendon+autografts%5BTitle%5D)+AND+%22Am+J+Sports+Med%22%5BJournal%5D)">Anterior cruciate ligament reconstruction: a systematic review and meta-analysis of outcomes for quadriceps tendon autograft versus bone-patellar tendon-bone and hamstring-tendon autografts.</a> Am J Sports Med. 47 (14), 3531-3540 (2019).</li>
<li>Mert, A., Cinaroglu, S., Keleş, H., Aydin, M., Çiçek, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Evaluation+of+autografts+used+in+anterior+cruciate+ligament+reconstruction+in+terms+of+tensile+strength%5BTitle%5D)+AND+%22Cureus%22%5BJournal%5D)">Evaluation of autografts used in anterior cruciate ligament reconstruction in terms of tensile strength.</a> Cureus. 15 (6), e39927(2023).</li>
<li>Orchard, J. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Fifteen-week+window+for+recurrent+muscle+strains+in+football%3A+a+prospective+cohort+of+3600+muscle+strains+over+23+years+in+professional+Australian+rules+football%5BTitle%5D)+AND+%22Br+J+Sports+Med%22%5BJournal%5D)">Fifteen-week window for recurrent muscle strains in football: a prospective cohort of 3600 muscle strains over 23 years in professional Australian rules football.</a> Br J Sports Med. 54 (18), 1103-1107 (2020).</li>
<li>Baumgart, C., Welling, W., Hoppe, M. W., Freiwald, J., Gokeler, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Angle-specific+analysis+of+isokinetic+quadriceps+and+hamstring+torques+and+ratios+in+patients+after+ACL+reconstruction%5BTitle%5D)+AND+%22BMC+Sports+Sci+Med+Rehabil%22%5BJournal%5D)">Angle-specific analysis of isokinetic quadriceps and hamstring torques and ratios in patients after ACL reconstruction.</a> BMC Sports Sci Med Rehabil. 10, 23(2018).</li>
<li>Girdwood, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((No+sign+of+weakness%3A+a+systematic+review+and+meta-analysis+of+hip+and+calf+muscle+strength+after+anterior+cruciate+ligament+injury%5BTitle%5D)+AND+%22Br+J+Sports+Med%22%5BJournal%5D)">No sign of weakness: a systematic review and meta-analysis of hip and calf muscle strength after anterior cruciate ligament injury.</a> Br J Sports Med. 58 (9), 500-510 (2024).</li>
<li>He, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Peroneus+longus+tendon+autograft+has+functional+outcomes+comparable+to+hamstring+tendon+autograft+for+anterior+cruciate+ligament+reconstruction%3A+a+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Knee+Surg+Sports+Traumatol+Arthrosc%22%5BJournal%5D)">Peroneus longus tendon autograft has functional outcomes comparable to hamstring tendon autograft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis.</a> Knee Surg Sports Traumatol Arthrosc. 29 (9), 2869-2879 (2021).</li>
<li>Kerimoğlu, S., Aynaci, O., Saraçoğlu, M., Aydin, H., Turhan, A. U. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Peroneus+longus+tendonu+ile+%C3%B6n+%C3%A7apraz+ba%C4%9F+rekonstr%C3%BCksiyonu.+Anterior+cruciate+ligament+reconstruction+with+the+peroneus+longus+tendon%5BTitle%5D)+AND+%22Acta+Orthop+Traumatol+Turc%22%5BJournal%5D)">Peroneus longus tendonu ile ön çapraz bağ rekonstrüksiyonu. Anterior cruciate ligament reconstruction with the peroneus longus tendon.</a> Acta Orthop Traumatol Turc. 42 (1), 38-43 (2008).</li>
<li>Zhao, J., Huangfu, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+biomechanical+and+clinical+application+of+using+the+anterior+half+of+the+peroneus+longus+tendon+as+an+autograft+source%5BTitle%5D)+AND+%22Am+J+Sports+Med%22%5BJournal%5D)">The biomechanical and clinical application of using the anterior half of the peroneus longus tendon as an autograft source.</a> Am J Sports Med. 40 (3), 662-671 (2012).</li>
<li>Angthong, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+anterior+cruciate+ligament+reconstruction+with+the+peroneus+longus+tendon%3A+A+biomechanical+and+clinical+evaluation+of+the+donor+ankle+morbidity%5BTitle%5D)+AND+%22J+Med+Assoc+Thai%22%5BJournal%5D)">The anterior cruciate ligament reconstruction with the peroneus longus tendon: A biomechanical and clinical evaluation of the donor ankle morbidity.</a> J Med Assoc Thai. 98 (6), 555-560 (2015).</li>
<li>Jowett, A. J., Sheikh, F. T., Carare, R. O., Goodwin, M. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Location+of+the+sural+nerve+during+the+posterolateral+approach+to+the+ankle%5BTitle%5D)+AND+%22Foot+Ankle+Int%22%5BJournal%5D)">Location of the sural nerve during the posterolateral approach to the ankle.</a> Foot Ankle Int. 31 (10), 880-883 (2010).</li>
<li>Tapasvi, S. R., Shekhar, A., Patil, S. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Anatomic+posterolateral+corner+reconstruction+with+autogenous+peroneus+longus+Y+graft+construct%5BTitle%5D)+AND+%22Arthrosc+Tech%22%5BJournal%5D)">Anatomic posterolateral corner reconstruction with autogenous peroneus longus Y graft construct.</a> Arthrosc Tech. 8 (12), e1501-e1509 (2019).</li>
<li>Luo, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Preoperative+ultrasound+can+accurately+predict+the+diameter+of+double-stranded+peroneus+longus+tendon+autografts%5BTitle%5D)+AND+%22Knee+Surg+Sports+Traumatol+Arthros.c%22%5BJournal%5D)">Preoperative ultrasound can accurately predict the diameter of double-stranded peroneus longus tendon autografts.</a> Knee Surg Sports Traumatol Arthros.c. 31 (8), 3362-3368 (2023).</li>
<li>He, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Low+to+moderate+risk+of+nerve+damage+during+peroneus+longus+tendon+autograft+harvest%5BTitle%5D)+AND+%22Knee+Surg+Sports+Traumatol+Arthrosc%22%5BJournal%5D)">Low to moderate risk of nerve damage during peroneus longus tendon autograft harvest.</a> Knee Surg Sports Traumatol Arthrosc. 30 (1), 109-115 (2022).</li>
<li>Wu, S., Rothrauff, B., Li, J., He, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Minimizing+the+risk+of+iatrogenic+nerve+injury+during+peroneus+longus+tendon+autograft+harvest%3A+A+cadaveric+study+at+different+ankle+or+knee+positions%5BTitle%5D)+AND+%22Knee+Surg+Sports+Traumatol+Arthrosc%22%5BJournal%5D)">Minimizing the risk of iatrogenic nerve injury during peroneus longus tendon autograft harvest: A cadaveric study at different ankle or knee positions.</a> Knee Surg Sports Traumatol Arthrosc. 31 (6), 2454-2460 (2023).</li>
<li>Goss, D. A. Jr, Reb, C. W., Philbin, T. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Anatomic+structures+at+risk+when+utilizing+an+intramedullary+nail+for+distal+fibular+fractures%3A+A+cadaveric+study%5BTitle%5D)+AND+%22Foot+Ankle+Int%22%5BJournal%5D)">Anatomic structures at risk when utilizing an intramedullary nail for distal fibular fractures: A cadaveric study.</a> Foot Ankle Int. 38 (8), 916-920 (2017).</li>
<li>Joshi, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Peroneus+longus+tendon+autograft+for+anterior+cruciate+ligament+reconstruction%3A+a+safe+and+effective+alternative+in+nonathletic+patients%5BTitle%5D)+AND+%22Niger+J+Surg%22%5BJournal%5D)">Peroneus longus tendon autograft for anterior cruciate ligament reconstruction: a safe and effective alternative in nonathletic patients.</a> Niger J Surg. 27 (1), 42-47 (2021).</li>
<li>Oliveira, D. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Anterior+cruciate+and+anterolateral+ligament+reconstruction+using+hamstring+and+peroneus+longus+tendons%3A+surgical+technique+description%5BTitle%5D)+AND+%22Arthrosc+Tech%22%5BJournal%5D)">Anterior cruciate and anterolateral ligament reconstruction using hamstring and peroneus longus tendons: surgical technique description.</a> Arthrosc Tech. 10 (2), e397-e402 (2021).</li>
<li>Rhatomy, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Single+bundle+ACL+reconstruction+with+peroneus+longus+tendon+graft%3A+2-years+follow-up%5BTitle%5D)+AND+%22J+Clin+Orthop+Trauma%22%5BJournal%5D)">Single bundle ACL reconstruction with peroneus longus tendon graft: 2-years follow-up.</a> J Clin Orthop Trauma. 11 (Suppl 3), S332-S336 (2020).</li>
</ol>

The authors declare that they have no competing interests.

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&#39;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...

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 tendon2,3,4. While these autograft sources offer efficacy, they share a commonality in being integral components of the knee&#39;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&#39;s return to sports5,6,7.
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 paresthesia9,10. 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-analysis8,10,11. 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.

<table><tbody><tr><td>Ultrasound</td><td>GE LOGIQ, USA</td><td></td><td>12-13 MHz linear array transducer&amp;nbsp;</td></tr><tr><td>General surgical instruments</td><td>Smtih &amp;amp; Nephew, USA</td><td></td><td></td></tr><tr><td>Tendon Stripper</td><td>Smtih &amp;amp; Nephew, USA</td><td></td><td>Closed blunt-ended tendon stripper</td></tr></tbody></table>

harvesting of peroneus longus tendon autograft

Harvesting of Peroneus Longus Tendon Autograft

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.

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...

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.

Autografts are always used in anterior cruciate ligament (ACL) reconstruction. Traditional sources, such as hamstring tendons, bone-patellar tendon-bone, ...

[Announcer] Welcome to this instructional video on the practical for safely harvesting the peroneus longus tendon autograft. This method, outlined by Chi Liang and Jinshen from the Department of Osteopathic Surgery at The Third Xiangya Hospital of Central South University in China, aims to provide clinicians with a reliable technique for minimizing complications in orthopedic surgeries. The protocol was approved by the Human Ethics Committee of The Third Xiangya Hospital of Central South University, and informed constant was obtained from the patient prior to making the video for educational purposes. Let's dive into the critical steps of the practical. Step one, preoperative preparation. Use ultrasound to locate the PLT graft area above the posterior lateral malleolus, and predict the diameter of the PLT autograft by measuring the cross-sectional area at the proximal ending of this incision, one centimeter away. Position the patients pan or lateral decubitus, with the operative limb appropriately exposed, disinfected, and sterilely draped. Step two, incision location and tendon isolation. To begin, a one to two-centimeter longitudinal incision is made one centimeter posterior, and two centimeter proximal, to the midpoint of the lateral malleolus. Careful dissection through the subcutaneous tissue is performed, paying close attention to the preservation of the sural nerve. Step three, harvesting the tendon. Elevate the PLT and stitch the proximal part using a whip-stitch style for subsequent autograft harvest. Mark the distal portion with another type of suture. Transversely section the PLT with tissue scissors. Finally, harvest the full thickness PLT using a standard closed blunt-ended tendon stripper. Suture the distal portion of the PLT to the peroneus brevis tendon. Remember to keep the stripper parallel and superficial to the fibula to prevent injury to the superficial peroneal nerve. Harvesting should stop five centimeter below the fibular head to avoid injury to deep peroneal nerve. Step four, postoperative care. Schedule follow-up appointments for wound assessment, suture removal, and rehabilitation progression. Now, let's discuss some representative results. In our study, we evaluated the American Orthopedic Foot and Ankle Society score and donor paresthesia in 20 patients to PLT harvest, both pre-operation and post-operation. Our findings show that harvesting the PLT with this protocol did not lead to significant complications, as shown in the table. In conclusion, this method holds great promise. It provides a reliable and customizable autograft source for a variety of orthopedic surgeries, offering advantages in terms of strength, minimal morbidity, and tissue compatibility. Its potential applications extend to ACL reconstruction, ankle stabilization, and other osteopathic procedures, ultimately enhancing patient outcomes and reducing the risk of graft-related complications.

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Learn a reliable method for harvesting the peroneus longus tendon autograft using ultrasound localization and closed tendon stripper techniques. This protocol minimizes complications and enhances outcomes in orthopedic surgeries.

Harvesting of Peroneus Longus Tendon Autograft

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