Peroneus Longus Versus Hamstring Tendon Graft for Anterior Cruciate Ligament Reconstruction: A Retrospective Matched Comparison

<b>Background/Objectives</b>: This study aimed to compare clinical and functional outcomes of anterior cruciate ligament reconstruction (ACLR) using peroneus longus tendon (PLT) versus hamstring tendon (HT) autografts in matched cohorts. <b>Materials and Methods</b>: A retrospective matched cohort study with 1:1 nearest-neighbor matching without replacement on sex (exact), age (±3 years), and time to last follow-up (closest match) was performed on consecutive primary single-bundle ACLR cases. After exclusions and follow-up completion, 77 PLT patients were matched 1:1 with 82 HT patients based on age, sex, and follow-up. Outcomes included the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm Knee Score, Tegner Activity Scale, Tampa Scale for Kinesiophobia, knee range of motion, manual strength testing, stability tests, limb circumferences, and the Single-Leg Hop test. Additionally, ankle-specific function in the PLT group was assessed using the AOFAS and FADI scores. <b>Results</b>: Graft diameter was larger with PLT (8.5 ± 0.6 mm) than with HT (8.1 ± 0.7 mm; <i>p</i> = 0.003). Both groups demonstrated significant improvement from the preoperative to the postoperative period on the IKDC, Lysholm, and Tegner scores (all <i>p</i> < 0.001). Between groups, postoperative IKDC and Lysholm scores were comparable (both <i>p</i> > 0.05), and Tegner scores did not differ significantly (<i>p</i> > 0.05). Knee flexion loss was less frequent (9.1% vs. 68.3%; <i>p</i> = 0.001), and knee flexion strength was higher (4.7 ± 0.5 vs. 4.0 ± 0.8; <i>p</i> = 0.001) in PLT. Stability tests, LSI, extension strength, and limb circumferences were similar (all <i>p</i> > 0.05). Saphenous nerve symptoms were less frequent with PLT (13.0% vs. 29.3%; <i>p</i> = 0.010). Ankle function in PLT was preserved (AOFAS 96.9 ± 7.9; FADI 97.4 ± 8.5) with mild eversion limitation in 3 patients (3.9%). Re-rupture rates were low and did not differ significantly between groups (<i>p</i> > 0.05). Infections occurred only after HT, yielding a between-group difference (<i>p</i> = 0.030). <b>Conclusions</b>: PLT autografts provide clinical and functional outcomes comparable to those of HT, with advantages including a larger graft diameter, better preservation of knee flexion function, fewer symptoms related to the saphenous nerve, and excellent ankle outcomes. PLT is a safe and effective alternative for primary ACLR.