DISTAL PERONEUS LONGUS STUMP TENODESIS VERSUS FREE TENOTOMY AFTER PERONEUS LONGUS TENDON HARVEST FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A SYSTEMATIC REVIEW WITH LIMITED META-ANALYSIS

Abstract

Background: Peroneus longus tendon (PLT) autograft is increasingly used in anterior cruciate ligament reconstruction (ACLR). Some surgeons routinely tenodese the distal peroneus longus stump to the peroneus brevis to reduce donor-ankle morbidity, whereas others leave the stump free after tenotomy. The incremental benefit of stump tenodesis remains uncertain.
Purpose: To systematically review and, where possible, quantitatively synthesize comparative evidence on distal PLT stump tenodesis versus free tenotomy/no tenodesis in ACLR using PLT autograft.
Methods: A systematic search was performed for comparative studies evaluating ACLR with PLT autograft in which the donor-site technique included distal PL-to-PB tenodesis/suturing versus no tenodesis/free tenotomy. Outcomes of interest included AOFAS, FADI or VAS-FA scores, ankle plantarflexion/eversion strength, radiographic or footprint-based arch morphology, donor-site complications, and knee outcomes. PRISMA 2020 principles were followed. Risk of bias was appraised using RoB 2 for randomized studies and ROBINS-I for non-randomized comparative studies. Meta-analysis was planned with inverse-variance random-effects models when at least two studies reported comparable parametric outcomes. When pooling was not statistically appropriate, a single-study effect estimate and structured qualitative synthesis were presented.
Results: Two comparative studies met inclusion criteria: one randomized controlled trial reported as an ISAKOS 2023 ePoster (n=24) and one retrospective comparative cohort published in 2026 (n=60). Both studies found no clinically meaningful superiority of distal stump tenodesis over no tenodesis. The RCT showed no significant between-group differences at 6 months for AOFAS, VAS-FA, Clarke angle, or first-ray plantarflexion strength. The cohort showed similarly high AOFAS and FADI scores and no clinically relevant deficits in ankle motion or strength at final follow-up. Because only one study provided means and standard deviations for validated final ankle scores, pooled meta-analysis was not possible. In that study, the mean difference favored tenodesis by 2.30 points for AOFAS (95% CI -0.34 to 4.94) and 1.50 points for FADI (95% CI -1.21 to 4.21), below commonly meaningful clinical thresholds.
Conclusion: Current comparative evidence is sparse and does not demonstrate a clinically meaningful benefit of distal peroneus longus stump tenodesis to peroneus brevis over free tenotomy/no tenodesis after PLT harvest for ACLR. Routine tenodesis cannot be considered evidence-mandated; however, existing data are limited by small sample size, short to medium follow-up, and incomplete reporting. Larger randomized trials with standardized isokinetic testing, gait analysis, validated ankle PROMs, and long-term arch morphology assessment are required.
Level of evidence: Level III, systematic review of one randomized trial and one retrospective comparative cohort.