Broader perspective on the role of peroneus longus tendon in ligament reconstruction

Abstract

This article offers additional clinical and biomechanical insights into using the peroneus longus tendon (PLT) autograft in posterior cruciate ligament reconstruction. While recent studies report favorable knee outcomes, concerns remain regarding donor site morbidity. The PLT plays a key role in foot biomechanics, and its harvesting may lead to subtle changes, as suggested by imaging and pedobarographic studies. Tendon regeneration may limit long-term morbidity, but further studies are needed. We recommend that future research include gait analysis, long-term follow-up, and insights from anterior cruciate ligament literature.

Key Words: Peroneus longus tendon; Autograft; Reconstruction; Ankle; Regenerative

Core Tip: This article used biomechanical and imaging data from the anterior cruciate ligament reconstruction literature to highlight the importance of considering the long-term consequences of donor site morbidity in peroneus longus tendon (PLT) grafting. It discusses the functional role of the PLT in foot and ankle biomechanics, highlights concerns raised by tendon harvesting, and cites studies demonstrating possible tendon regeneration. The article advocates for future research, including gait analysis and long-term follow-up, to ensure safe and effective graft selection.

TO THE EDITOR

We read with great interest the recent meta-analysis evaluating the use of the peroneus longus tendon (PLT) autograft for posterior cruciate ligament reconstruction. The study demonstrated promising functional outcomes and reflects the growing interest in PLT as a viable graft option for cruciate ligament surgery[1]. While these findings are encouraging, we would like to offer a broader biomechanical and clinical perspective on the role of the PLT in ligament reconstruction, particularly regarding donor site morbidity.

In the current literature, the focus is generally limited to knee joint function, with insufficient emphasis on functional effects on the foot and ankle.In addition to serving as a structural graft, the PLT functions as a dynamic stabilizer in ankle biomechanics. It plays a key role in foot eversion, plantarflexion, and maintaining the integrity of the medial longitudinal arch[2,3]. This role in lower extremity kinematics suggests that harvesting the PLT may lead not only to improved clinical scores but also broader functional effects. Long-term outcomes from anterior cruciate ligament reconstruction suggest that harvesting the PLT may lead to subtle biomechanical changes in foot function. Pedobarographic studies have demonstrated alterations in plantar pressure distribution, even without changes in standard clinical scores[4]. Furthermore, cadaveric and imaging studies underscore the role of PLT in stabilizing the first metatarsal and preserving the transverse arch of the foot[2,5].

These anatomical features support a more controlled and individualized approach to graft selection in patients with underlying foot deformities or instability. Interestingly, magnetic resonance imaging studies have shown that tendon-like tissue may regenerate within the sheath of the harvested PLT over time, potentially explaining the minimal donor site morbidity observed in long-term follow-up[5]. Nevertheless, additional studies are warranted to determine whether the regenerated tissue possesses sufficient structural integrity and functional capacity. This regenerative potential warrants further exploration, especially in physically active individuals, where even minor disruptions in foot stability may impair performance or predispose to secondary complications.

We commend the authors for their valuable contribution to the literature and recommend that future research on PLT grafts - particularly in the context of posterior cruciate ligament reconstruction - include advanced biomechanical evaluations, dynamic gait analysis, and long-term follow-up. Standardized protocols that include subjective and objective measurements could greatly increase the comparability and generalizability of future studies. Integrating insights from anterior cruciate ligament-related studies may help further elucidate the broader implications of PLT harvesting in knee ligament surgery.