Anterior cruciate ligament (ACL) injury is a common problem worldwide, particularly among those who participate in high-impact sports, have early-onset osteoarthritis with accompanying knee pain, and have a lower quality of life between the ages of 30 and 50 [1,2]. Surgical reconstruction is the preferred method of treatment for ACL injuries in the sports-active population, with the goal of returning to pre-injury levels of sports activity[3]. Several techniques of grafting in ACL reconstruction existed, but two prominent and commonly used are bone-patellar-tendon-bone (BPTB) and quadrupled hamstring grafting for an intra-articular reconstruction of an ACL-deficient knee[4], with no significant difference in functional outcomes between the two grafts[5]'.The success of ACL repair can be improved by using a rigorous fixation approach and a stronger graft selection[6-9].

As none of the autograft techniques are ideal but hamstring tendon graft has several limitations in spite of excellent mechanical strength i.e., weakness in knee-flexion[10], poor predictability of length and diameter[11], and saphenous nerve-injuries in infrapatellar branches[12]. BPTB is also not acceptable to patients due to patellar fracture and anterior knee pain[13], while contralateral hamstring tendons is not liked by patients causing delay in rehabilitation due to additional surgery in normal limb[10]. Though, peroneus longus autografting is not a new technique, which has been previously used in flatfoot deformity[14], low risk to nerve damage in knee-surgery[15], and to evaluate outcome of ACL-reconstruction[16].

To our knowledge, there is scarcity of literature to assess the safety and efficacy of single-bundle ACL-reconstruction because the use of peroneus longus autograft and suspensory fixation with femoral site endobutton and full tibial tunneling technique is becoming increasingly popular as a safe and effective alternative to hamstring autograft and fixation with femoral site endobutton and tibial site interference screw. For this purpose, present study tended to assess safety and efficacy of single-bundle ACL-reconstruction.

Our study was a descriptive case-series conducted in department of Orthopaedics, Hayatabad Medical Complex Peshawar, from Jan 2025 to June 2025. For this purpose 96 patients were chosen through consecutive non-probability sampling techniques, in which patients considered eligible were with unilateral ACL injury, maximum 2 weeks injury duration, baseline category C or D on International Knee Documentation Committee (IKDC) scoring and age ranged 20-50 years. While those who have taken any type of treatment for knee-injury was excluded because it may be a reason of biasness in our findings. First of all approval was taken from Institutional review board of the hospital under reference # 550-1/IRB/HMC and informed consents were taken, after explaining the purpose of the study and use of the data for research purpose to the patients.Then, detailed medical history was taken and ACL injury through MRI report was confirmed bya skilled orthopedic surgeon with at least five years of experience performed arthroscopic reconstruction using peroneus longus autograft and femoral and tibial suspensory fixation.Patients were kept in wards for day and then sent back to home while keeping them on analgesic. Also, patients were advised to revisit for follow-up after 6-weeks in order to find the functional-outcome on IKDC. During the whole process of treatment, medical ethics were strictly followed to make it beneficial to patients. Finally, Data was analysed using SPSS-23.

A total of 96 patients were included in the study. Patients mean age were 34.92±9.545 years and their injuries lasted an average of 4.11±1.562 weeks, as shown in Table 1.

TABLE 1: Mean and SD for age and duration of injury

According to Table 2, 42.7% of the patients were under 30 and 57.3% were over 30 years old. Also, there were 50-malepatients (60.4%) and38-female patients (39.6%). Furthermore, 61 (63.6%) injuries were caused by RTA, 15 (15.6%) were caused by assaults, and 20 (20.8%) were caused by Sports.89.6% of patients had functional results that were normal, 4.2% had outcomes that were close to normal, 3.1% had outcomes that were abnormal, and 3.1% had outcomes that were seriously abnormal.

TABLE 2: Characteristic of patients with frequency and percentages

Table-3 provides information on functional outcomes for patients with several characteristics; age, gender, causes of injury and duration of injury. Four types of functional outcomes have been established: normal, almost normal, abnormal, and severely abnormal. Patients under 30 years old had a greater proportion of normal functional results (92.7%) than patients over 30 years old (87.3%) with statistically non-significant (p=.317). Additionally, males had a lower percentage (87.9%) of normal functional results than females (92.1%) with significant difference existed (p=.027), which means treatment was efficient in females as compare to males. Considering the sources of injury, RTA (road traffic accidents) injuries had the greatest proportion (91.8%) of normal functional outcomes, followed by assaults (86.7%) and sports-related injuries (85.0%). Lastly, the length of the damage did not appear to significantly affect functional results. As comparison to patients with injuries lasting more than 3 weeks (85.0%), patients with injuries lasting less than 3 weeks had a greater proportion (97.2%) of normal functional outcomes. The distinction was not, however, statistically significant (p=.204).

TABLE 3:

TABLE 3: Stratification of Functional Outcomes on age, gender, causes if injury and duration of injury

The ACL plays a crucial role in maintaining knee stability, along with other ligaments, and is commonly ruptured during sports injuries or road accidents due to forceful valgus-external rotation[6]. The standard treatment for ACL-deficient knees involves intra-articular reconstruction, with the quadrupled hamstring and bone-patellar tendon-bone (BPTB) grafts being the most widely used procedures[5]. While, past studies have shown no difference in functional outcomes between the two grafts, researchers have focused on improving ACL repair by understanding the best graft type (autograft or allograft), tunnel location, and graft fixation to enhance survival and outcomes[6-9]. According to the findings, the patients' mean ages were 34.92±9.545 years and their injuries lasted an average of 4.11±1.562 weeks, as shown in Table 1. While, table 2 showed that 42.7% of the patients were under 30 and 57.3% were over 30 years old. Also, there were 58(60.4%) males and 38(39.6%) were female. Furthermore, 61(63.6%) injuries were caused by RTA, 15 (15.6%) were caused by assaults, and 20 (20.8%) were caused by Sports.Previous studies reported an average age of 35.4+8.8 years16, 32.1 years[17] and 28.73 years[17]. ACL-injury can be encountered at any age, but in our study, it was highly reported in >30 years, which is the age of high participation in combative sports. The results also showed that ACL-injury is reported to be higher in male-patients (60.4%) as compare to female-patients (39.6%), which is consistent with previous studies i.e., 58/96 for male, while 38/96 for females. Our results were consistent with previous findings i.e., 1.7 % higher in males[16] and 85% of patients were male[18]. The reasons attributed to such high involvement of males were due to the engagement strenuous activities, which need strong knees to be a part of such activities. Consequently, males choose such type of surgery more as compare to females. Our study indicated that RTA was more common cause of ACL-injury, which accounted 63.6%. Our findings also portrayed that 89.6% of patients had functional results that were normal, 4.2% had outcomes that were close to normal, 3.1% had outcomes that were abnormal, and 3.1% had outcomes that were seriously abnormal. Furthermore, table 3 provided information on functional outcomes for patients with several characteristics;age, gender, causes of injury and duration of injury. Four types of functional outcomes have been established: normal, almost normal, abnormal, and severely abnormal. Table 3 also showed patients under 30 years old had a greater proportion of normal functional results (92.7%) than patients over 30 years old (87.3%) with statistically non-significant (p=0.317). Additionally, males had a lower percentage (87.9%) of normal functional results than females (92.1%) with significant difference existed (p=.027), which means treatment was efficient in females as compare to males. Considering the sources of injury, RTA (road traffic accidents) injuries had the greatest proportion (91.8%) of normal functional outcomes, followed by assaults (86.7%) and sports-related injuries (85.0%). Lastly, the length of the damage did not appear to significantly affect functional results. As comparison to patients with injuries lasting more than 3 weeks (85.0%), patients with injuries lasting less than 3 weeks had a greater proportion (97.2%) of normal functional outcomes. The distinction was not, however, statistically significant (p=0.204).In a previous study, 79 patients were assessed and their mean pre-operative IKDC score of 38.95±5 showed improvement to 67.92±2 at 6 months and 90.73±7 at 12 months[19]. Another study was conducted with 48 patients who underwent ACL reconstruction with peroneus longus autograft, and 46 of them (95.83%) achieved a normal functional outcome on IKDC scoring[20]. Our study included 41 patients (42.7%) in the age group <30 years and 55 patients (57.3%) in the age group >30 years (as shown in Table No. 2). Out of the total patients, 58 (60.4%) were male and 38(39.6%) were female. In terms of causes of injury, 15(15.6%) patients had assault, 20 (20.8%) had sports-related injuries, and 61(63.5%) had road traffic accidents. Regarding functional outcome, 86(89.6%) patients had a normal outcome, 4(4.2%) were near normal, 3(3.1%) were abnormal, and 3(3.1%) patients had a severely abnormal outcome, based on frequency and percentages. In conclusion, this study's findings showed that employing a peroneus longus tendon autograft for arthroscopic ACL restoration, together with femoral and tibial suspensory fixation for primary ACL reconstruction, is a safe treatment with excellent results. This suggests that peroneus longus tendon autograft may be an effective substitute for hamstring and BPTB autografts obtained from the knee area in single-bundle ACL reconstruction, without endangering ankle function and with a lower risk of complications.

The results of this study showed that using a peroneus longus autograft in arthroscopic ACL restoration with femoral and tibial suspensory fixation is a safe method with excellent primary ACL reconstruction outcomes. Peroneus longus tendon autograft is therefore suggested as a potential graft option for single-bundle ACL restoration. This shows that it could be a good option to hamstring and BPTB autografts taken from the knee area for ACL restoration because it doesn't jeopardise ankle function and doesn't run the risk of problems.

Additional Information

Disclosures

Human subjects: All authors have confirmed that this study did not involve human participants or tissue.

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

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