Butt Umer M, Khan Zainab A, Amin Amanullah, Shah Imran Ali, Iqbal Javed, Khan Zeeshan
AO Hospital, Karachi, Pakistan.
Hayatabad Medical Complex, Peshawar, Pakistan.
JBJS Essent Surg Tech. 2022 Jun 20;12(2):e20.00053. doi: 10.2106/JBJS.ST.20.00053. eCollection 2022 Apr-Jun.
There remains controversy regarding the ideal graft choice for anterior cruciate ligament (ACL) reconstruction. Bone-patellar tendon-bone and hamstring autografts have been considered the gold standard for decades. Despite the good clinical outcomes, donor-site morbidity is a concern for both of these grafts. Peroneus longus tendon autograft has also been considered as a potential graft for many orthopaedic reconstructive procedures. The biomechanical properties and thickness of such a graft permit its use for ACL reconstruction. The tensile strength of a peroneus longus tendon autograft is the same as that of a hamstring autograft and greater than that of a bone-patellar tendon-bone graft and a quadriceps tendon graft. We aimed to describe the steps to harvest the peroneus longus tendon autograft during single-bundle ACL reconstruction.
Identification of anatomical landmarks is performed, including the distal aspect of the fibula and the posterior border of the fibula, 2 cm above the tip of the bone. A longitudinal incision is made along the posterior border of the fibular bone, from 2cm above the tip of the fibula. Care is taken to identify the tendon sheath that covers the longus and brevis approximately 2 cm above the superior extensor retinaculum, and the peroneus longus is stitched to the peroneus brevis. The proximal aspect of the peroneus longus tendon is whipstitched, after which the peroneus longus tendon and surrounding soft tissues are incised. The peroneus longus tendon is then released with use of a closed stripper, and the graft is prepared.
Alternative nonoperative treatment options include physical therapy, nonsteroidal anti-inflammatory drugs, rest, and limitation of sporting activities. Alternative surgical treatment options include arthroscopic debridement, ACL repair or reconstruction with bone-patellar tendon-bone or hamstring-tendon autograft, and ACL reconstruction with allograft.
Recent studies have shown that ACL reconstruction with use of a peroneus longus tendon autograft is safe and effective, with less donor-site morbidity compared with other tendon autografts.
The peroneus longus graft has been accepted for ligament reconstruction because of its strength, safety, and less donor-site morbidity. The peroneus longus graft allows surgeons to harvest the autograft via a relatively small incision, resulting in fewer donor-site complications. According to Rhatomy et al., the use of a peroneus longus graft provides good functional outcomes that are comparable with those of a hamstring autograft, but it has a larger graft diameter and its harvest results in less thigh hypotrophy. Additionally, a case series of 10 patients who underwent ACL reconstruction with use of a peroneus longus autograft showed satisfactory Lysholm scores and low disability according to the Foot and Ankle Disability Index.
Examination under anesthesia and arthroscopic confirmation of the ACL tear are recommended prior to harvesting the peroneus longus tendon.Take care to identify the anatomical landmarks of the peroneus longus and brevis.Tenodesis of the peroneus longus to the brevis is performed first, followed by whipstitching of the peroneus longus proximal to the site of the tenodesis.Once the peroneus longus tendon is passed through the closed stripper, gently maintain traction on the sutures while pushing the stripper proximally until the tendon is freed.Care should be taken not to damage the superior peroneal retinaculum, which provides the primary restraint to tendon subluxation.Identification of the peroneus longus and brevis is important. The peroneus longus tendon is free of muscle attachment and more rounded in shape, while the peroneus brevis contains muscle fibers.
ACRONYMS & ABBREVIATIONS: PL = peroneus longusCI = confidence intervalIKDC = International Knee Documentation Committee.
关于前交叉韧带（ACL）重建的理想移植物选择仍存在争议。几十年来，骨-髌腱-骨和腘绳肌自体移植物一直被视为金标准。尽管临床效果良好，但供区并发症是这两种移植物都需要考虑的问题。腓骨长肌腱自体移植物也被认为是许多骨科重建手术的潜在移植物。这种移植物的生物力学特性和厚度使其可用于ACL重建。腓骨长肌腱自体移植物的拉伸强度与腘绳肌自体移植物相同，且大于骨-髌腱-骨移植物和股四头肌肌腱移植物。我们旨在描述单束ACL重建术中获取腓骨长肌腱自体移植物的步骤。
确定解剖标志，包括腓骨远端和腓骨尖上方2厘米处的腓骨后缘。沿腓骨后缘从腓骨尖上方2厘米处做一纵向切口。注意识别在伸肌支持带上方约2厘米处覆盖腓骨长肌和腓骨短肌的腱鞘，并将腓骨长肌缝合至腓骨短肌。对腓骨长肌腱的近端进行褥式缝合，然后切开腓骨长肌腱及其周围软组织。接着使用闭合剥离器松解腓骨长肌腱，制备移植物。
替代的非手术治疗选择包括物理治疗、非甾体类抗炎药、休息和限制体育活动。替代的手术治疗选择包括关节镜下清创、用骨-髌腱-骨或腘绳肌腱自体移植物进行ACL修复或重建，以及用同种异体移植物进行ACL重建。
最近的研究表明，使用腓骨长肌腱自体移植物进行ACL重建是安全有效的，与其他肌腱自体移植物相比，供区并发症更少。
腓骨长肌移植物因其强度、安全性和较少的供区并发症而被接受用于韧带重建。腓骨长肌移植物使外科医生能够通过相对较小的切口获取自体移植物，从而减少供区并发症。根据Rhatomy等人的研究，使用腓骨长肌移植物可提供与腘绳肌自体移植物相当的良好功能结果，但它的移植物直径更大，获取后导致的大腿肌肉萎缩更少。此外，一项对10例使用腓骨长肌自体移植物进行ACL重建的患者的病例系列研究显示，根据足踝残疾指数，患者的Lysholm评分令人满意且残疾程度较低。
建议在获取腓骨长肌腱之前进行麻醉下检查和关节镜确认ACL撕裂。注意识别腓骨长肌和腓骨短肌的解剖标志。先将腓骨长肌与腓骨短肌进行固定术，然后在固定部位近端对腓骨长肌进行褥式缝合。一旦腓骨长肌腱穿过闭合剥离器，在向近端推动剥离器时轻轻保持对缝线的牵引，直到肌腱松解。应注意不要损伤腓骨上支持带，它是防止肌腱半脱位的主要结构。识别腓骨长肌和腓骨短肌很重要。腓骨长肌腱没有肌肉附着，形状更圆，而腓骨短肌含有肌肉纤维。
PL = 腓骨长肌；CI = 置信区间；IKDC = 国际膝关节文献委员会
