Peroneus Longus Tendon Versus Hamstring Tendon Autograft for Primary Anterior Cruciate Ligament (ACL) Reconstruction: A Systematic Review and Meta-Analysis

Anterior cruciate ligament (ACL) reconstruction remains one of the most commonly performed orthopedic procedures worldwide, with graft selection representing a key determinant of postoperative outcomes. In recent years, the peroneus longus tendon has emerged as a promising alternative to the traditionally used hamstring tendon autograft. Previous meta-analyses have suggested comparable or favorable outcomes; however, several new randomized controlled trials and observational studies have since been published, necessitating an updated synthesis of the evidence. This systematic review and meta-analysis, therefore, aims to comprehensively evaluate and compare the clinical, functional, and stability outcomes of peroneus longus tendon versus hamstring tendon autografts in primary ACL reconstruction. A systematic literature search was conducted across PubMed, Cochrane Library, Web of Science, and Embase from inception until January 2026. Studies comparing the peroneus longus tendon with hamstring tendon autografts reporting at least one predefined outcome were eligible for inclusion. A total of 32 studies comprising 10 randomized controlled trials and 22 observational studies were included. Pooled analyses were performed using random-effects models, with outcomes reported as mean differences (MDs) or odds ratios with 95% confidence intervals. No statistically significant differences were observed between the two groups in terms of International Knee Documentation Committee (IKDC) score (MD: -0.74, 95% CI: -1.58 to 0.09) or Lysholm score (MD: -0.50, 95% CI: -1.17 to 0.18). Additionally, objective knee stability measures, including the anterior drawer, Lachman, and pivot shift tests, were also not significantly different between the two groups. Subgroup analysis of randomized controlled trials demonstrated significantly higher IKDC and Lysholm scores in the peroneus longus tendon group. Patients in the hamstring tendon group exhibited significantly greater thigh circumference reduction compared to the peroneus longus tendon group (MD: 0.92 cm, 95% CI: 0.72 to 1.11), indicating more pronounced donor site muscle atrophy. Ankle function, assessed by American Orthopaedic Foot and Ankle Society (AOFAS) scores, remained comparable between groups. Peroneus longus tendon autograft demonstrates comparable functional and stability outcomes to hamstring tendon autograft while offering superior preservation of thigh muscle mass. These findings support its consideration as a viable alternative graft option in primary ACL reconstruction, particularly in patients where minimizing knee donor site morbidity is a priority.