Functional Outcome of Chronic Anterior Cruciate Ligament Rupture Reconstruction Using Peroneus Longus Tendon Graft According to AOFAS and IKDC Score: A Case Series

Is the anterolateral ligament the smoking gun to explain rotational knee laxity or just vaporware?

Background: Anterior cruciate ligament (ACL) reconstruction using the peroneus longus tendon (PLT) graft is emerging as a viable alternative to traditional autografts, offering comparable strength and reduced donor site morbidity. This study evaluates the functional outcomes and complications of ACL reconstruction using this PLT graft. Methods: A hospital-based prospective study was conducted on 50 patients with isolated ACL tears. Outcomes, including Lysholm, IKDC, Tegner activity, and modified Cincinnati scores, were assessed preoperatively and postoperatively at 6 and 12 months. Visual analog scale (VAS), range of motion (ROM), and complications were also recorded. Statistical significance was set at p<0.05. Results: Significant improvements were observed in Lysholm (46.2±10.3 to 89.4±6.7), IKDC (38.1±9.7 to 85.2±5.9), and modified Cincinnati (37.5±8.2 to 85.3±5.1) scores (p<0.001). ROM increased from 115°±15° to 140°±5°, and pain (VAS) decreased from 7.4±1.2 to 1.5±0.7. Complications were minimal, with a 2% graft failure rate and mild donor site morbidity. Conclusions: ACL reconstruction with the peroneus longus graft provides excellent functional outcomes and minimal complications, making it a reliable alternative to conventional autografts.

Recently the peroneus longus tendon (PLT) gained popularity in anterior cruciate ligament (ACL) reconstruction and has been utilized with satisfactory outcomes. However, there are concerns regarding donor site morbidity. This study aims to compare the functional outcome of ACL reconstruction using hamstring (HT) and PLT autografts and evaluate the donor site morbidity. Patients who underwent ACL reconstruction were allocated to two groups (HT and PLT). Graft diameter was measured intraoperatively. Knee functional outcome was evaluated with IKDC and Tegner-Lysholm scores preoperatively, and postoperatively after 3 months, 6 months, and 1 year. Donor site morbidities were assessed with thigh circumference measurements, subjective evaluation of sensory disturbances, and ankle scoring with AOFAS and FADI scores. At 1-year follow-up, the PLT group showed comparable IKDC (p = 0.925) and Tegner-Lysholm (p = 0.600) scores with those of the HT group. The mean graft diameter in the PLT group (7.93 ± 0.52mm) was larger compared with the HT group (7.43 ± 0.50mm) (p < 0.001). The incidence of thigh atrophy (HT-16.7%, PLT-10%) and sensory disturbances (HT-73.3%, PLT-10%) was greater in the HT group. There was no significant ankle donor site morbidity in the PLT group (AOFAS-98.67 ± 3.45, FADI-99.23 ± 1.69). ACL reconstruction with PLT had comparable functional outcome with that of HT at 1 year. However, PLT demonstrated larger graft diameter, less donor site morbidity, and enhanced muscle recovery without significantly affecting the ankle function. PLT can be safely used as an acceptable alternative graft choice harvested from outside the knee for ACL reconstruction.

The aim of this study was to compare the outcomes between anteromedial (AM) and transtibial (TT) femoral tunnel positioning techniques for the reconstruction of chronic anterior cruciate ligament (ACL) rupture. It is a randomized prospective study of 106 patients who underwent ACL reconstruction because of a chronic ACL rupture (55 AMT, 51 TT). Minimum follow-up was 2years. Demographic, clinical and radiological data, including MRI grafts' anatomy and biomechanics intraoperative navigation system evaluation, were analyzed. Also, International Knee Documentation Committee score, Tegner Knee score, Lysholm Knee Score, Short-Form Health Survey and 4-point Likert Scale were evaluated. The AM technique achieves a more anatomic graft than TT technique in both sagittal and coronal plane (6° approximately). Immediate postoperative biomechanical evaluation of the graft showed both techniques significantly improved translational and rotational laxity (p = 0.000). AMT showed superiority only in controlling internal rotation (p = 0.016). Both techniques reported significant improvement in all evaluated score scales, without differences between techniques. Independently of the femoral tunnel positioning technique, patients with cartilage lesion had worse clinical outcomes. Our findings suggest that AMT achieves a more anatomical and biomechanically accurate graft allowing better control over internal rotation laxity; however, this does not lead to better clinical outcomes if we compare with TT in the reconstruction of chronic ACL rupture. Patients with chronic ACL rupture and cartilage lesion had worse clinical outcomes, independently the femoral tunnel positioning technique.

The purpose of the current randomized clinical trial (RCT) was to evaluate the clinical outcomes of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction and to compare them with those of isolated ACL reconstruction. The hypothesis was that combined ACL and ALL reconstruction will result in superior clinical outcomes in terms of the rotational stability of the knee. This prospective RCT included 57 patients (44 men and 13 women, mean age = 31 ± 7.1 years) who underwent ACL reconstruction either isolated (Group I: 25 patients) or combined with ALL reconstruction (Group II: 32 patients). The evaluation of the patients was done preoperatively and postoperatively at 6 weeks, 12 weeks, 6 months, and 12 months including a clinical examination (Lachman's test, Pivot shift's test, and Rolimeter differential anterior laxity), an objective clinical scores (objective: the International Knee Documentation Committee [IKDC] score) and a subjective clinical scores (subjective: IKDC's score, Lysholm's score, and Tegner's activity score). Postoperative complications of all the patients were recorded. There was a significant difference between the study groups at all follow-up intervals when evaluating the postoperative pivot shift test (p < 0.05) with a superior rotational stability in the group of combined ACL and ALL reconstruction. At the final follow-up evaluation, 36% of the patients from Group I and 6.2% in Group II had a grade I positive pivot shift test (p < 0.05). There was a statistically significant difference between the two groups regarding the number of patients with a grade A IKDC objective score (p < 0.05) at the 6- and 12-month follow-up intervals (p = 0.007). There was a significant difference concerning the IKDC subjective score between the two study groups in favor of the combined ACL and ALL reconstruction group at 12 months postoperatively (p = 0.048). Combined ACL and ALL reconstruction technique was demonstrated to be effective in obtaining a superior control of the rotational knee instability and to improve the clinical objective and subjective outcomes when compared with isolated ACL reconstruction in sports patients with high-grade pivoting shifts.

Objectives:Anterior cruciate ligament (ACL) injury has an annual incidence of more than 200,000 cases with almost 100,000 undergoing ACL reconstruction (ACLR). Many institutions have built ACL registries to better understand treatment outcomes and raise overall standards of care. One limitation of these registries is the continued compliance of patients to fill out post-operative patient-reported outcome surveys over time, with most beginning data collection 2 years after surgery. With most ACLR patients returning to activities or sport between 1 and 2 years after surgery, and registry attrition rates increasing with every year removed from surgery, it would be beneficial to focus follow-up data collection beginning 1-year post-operatively. The purpose of this study was to evaluate if a clinically meaningful change exists from 1 to 2-year follow-up in patient-reported outcome measures for patients undergoing ACL reconstruction.Methods:Patients who underwent primary ACLR from 2010 and 2012 in our institution’s ACL registry were included. IKDC Subjective and Marx Activity surveys were collected pre-operatively and at 1 and 2-year follow-ups. Two-way repeated measures ANOVA was used to evaluate changes in IKDC and Marx scores. Differences between ages, sex, graft type, and meniscal and cartilage pathology were assessed. Bonferroni-adjusted post hoc tests were used to assess pairwise comparisons of each time point. Chi-square tests were used to compare the proportion of patients who attained minimally clinically important difference (MCID) from 1 to 2 years.Results:1,037 enrolled patients underwent ACL reconstruction from 2010 to 2012 - 893 being primary procedures. IKDC or Marx surveys were available in 289 patients. Overall, IKDC scores significantly improved from baseline to 1 year (32.9 points, p<0.001). Overall change in IKDC was statistically significant from 1 to 2 years; however, mean change was 3.2 points, well below published MCIDs. Only 12% of patients attained clinically relevant change from 1 to 2 years. Range of IKDC scores between various factors was 0.5 to 5.6 points. There was no difference in percentage of those who reach the MCID between factors. Change in Marx scores was significant from baseline to 1 year (-2.2, p<0.001), but not significant from 1 to 2 years (0.1, p>0.999). Mean change was not significant between groups, with mean scores ranging from -0.6 to 1.0 from 1 to 2 years.Conclusion:Significant and meaningful changes were found in IKDC and Marx scores from baseline to 1-year follow-up. However, no clinically meaningful difference was found in both IKDC and Marx scores from 1 to 2 years follow-up. To our knowledge, this is the first study to look at longitudinal evaluation of patient-reported outcomes at these given time points with a high volume of patients. Future studies should look at why there is no significant change between 1 and 2 year outcomes, but given the lack of a clinically relevant change from 1 to 2 years and the challenges and resources required for patient follow-up, ACL-related studies should consider collecting 1 year outcome surveys to maximize follow-up retention in their patient cohort along with complementing this data with additional relevant outcome assessments such as radiographic evaluation and functional tests that measure readiness to return to play.Table 1:Change in IKDC and Marx scores by various patient and clinical characteristicsIKDCMarxBL1YR2YRIKDC Change(BL vs. 1YR)IKDC Change(1YR vs. 2YR)BL1YR2YRMarx Change(BL vs. 1YR)Marx Change(1YR vs. 2YR)Overall, mean (SE)51.0 (0.9)80.8 (0.8)84.0 (0.8)32.9 (1.0)•3.2 (0.6)•11.3 (0.3)9.0 (0.3)9.1 (0.3)-2.2 (0.3)•0.1 (0.2)Sex Male51.5 (1.3)81.3 (1.1)84.9 (1.1)33.4 (1.4)•3.6 (0.8)•11.3 (0.4)9.3 (0.4)9.5 (0.4)-1.8 (0.4)•0.2 (0.3) Female50.5 (1.4)80.2 (1.2)83.0 (1.2)32.5 (1.5)•2.8 (0.9)•11.3 (0.4)8.8 (0.4)8.6 (0.4)-2.7 (0.4)•-0.2 (0.3)Age group <1852.0 (2.2)87.0 (1.9)90.4 (1.8)38.4 (2.4)•3.4 (1.4)14.2 (0.6)13.2 (0.6)13.1 (0.6)-1.1 (0.7)-0.1 (0.5) 19-2254.1 (3.1)80.4 (2.7)86.0 (2.6)31.8 (3.5)•5.6 (2.1)•12.7 (0.9)10.2 (0.9)11.2 (0.9)-1.5 (1.0)•1.0 (0.8) 22-2950.7 (1.9)79.1 (1.7)82.1 (1.6)31.4 (2.1)•3.0 (1.3)•10.7 (0.6)8.2 (0.5)8.4 (0.5)-2.3 (0.6)•0.2 (0.5) 30-3948.9 (2.0)77.8 (1.7)82.0 (1.6)33.2 (2.2)•4.2 (1.3)•9.4 (0.6)7.9 (0.6)7.3 (0.5)-2.1 (0.6)•-0.6 (0.5) 40-4953.2 (2.1)82.4 (1.8)82.9 (1.7)29.7 (2.3)•0.5 (1.4)11.2 (0.6)8.5 (0.6)8.6 (0.6)-2.6 (0.6)•0.1 (0.5) 50•47.0 (3.3)76.5 (2.9)81.2 (2.8)34.2 (3.7)•4.7 (2.2)10.3 (1.0)5.4 (1.0)5.9 (0.9)-4.4 (1.0)•0.5 (0.8)Meniscal tear No52.1 (1.4)81.1 (1.2)84.2 (1.2)32.1 (1.5)•3.1 (0.9)•11.1 (0.4)8.8 (0.4)9.1 (0.4)-2.0 (0.4)•0.3 (0.3) Yes49.8 (1.3)80.7 (1.1)83.8 (1.1)33.9 (1.4)•3.1 (0.8)•11.5 (0.4)9.3 (0.4)9.0 (0.4)-2.4 (0.4)•-0.3 (0.3)Cartilage defect No50.1 (1.0)80.8 (0.9)84.1 (0.9)34.0 (1.2)•3.3 (0.7)•11.7 (0.3)9.4 (0.3)9.4 (0.3)-2.3 (0.3)•-0.1 (0.3) Yes53.8 (2.0)81.2 (1.8)83.6 (1.7)29.9 (2.2)•2.5 (1.3)9.8 (0.6)7.7 (0.6)8.0 (0.6)-1.9 (0.6)•0.3 (0.5)Graft type Autograft48.9 (1.7)79.2 (1.5)82.0 (1.4)33.1 (1.9)•2.7 (1.1)•10.0 (0.5)7.7 (0.5)7.6 (0.5)-2.5 (0.5)•-0.2 (0.4) Allograft51.6 (1.1)81.5 (1.0)84.7 (0.9)33.1 (1.2)•3.2 (0.7)•11.8 (0.3)9.6 (0.3)9.7 (0.3)-2.1 (0.3)•0.1 (0.3)• Indicates a statistically significant change, p<0.05

The purpose of the present retrospective study was to evaluate the influence of posterolateral corner reconstruction on anterior cruciate ligament (ACL) reconstruction in terms of anterior laxity and clinical outcomes. We hypothesized that the effects of combined ACL and posterolateral corner reconstruction would be less satisfactory than those of isolated ACL reconstruction in terms of anterior laxity and clinical outcomes. We retrospectively studied sixty-nine patients who underwent ACL reconstruction from February 2001 to December 2005. Forty-six patients underwent isolated ACL reconstruction (Group I), and twenty-three patients underwent combined ACL and posterolateral corner reconstruction (Group II). Clinical outcomes were determined from data obtained before surgery and at the time of the twenty-four-month follow-up examination. Postoperatively, the mean side-to-side difference (and standard deviation) in anterior tibial translation, measured with a KT2000 arthrometer, was greater for Group I (2.2 ± 1.0 mm) than for Group II (1.6 ± 0.8 mm) (p = 0.031). Seven knees (15.2%) in Group I and two knees (8.7%) in Group II had grade-1 anterior translation. The mean Lysholm score was 93.2 in Group I and 90.1 in Group II (p = 0.392). Thirty-eight knees (82.6%) in Group I and twenty knees (87.0%) in Group II were classified as normal or nearly normal according to the International Knee Documentation Committee scoring system (p = 0.882). On the basis of the evaluation of ligamentous laxity with use of the KT2000 arthrometer, we observed that combined ACL and posterolateral corner reconstruction allows less anterior translation than isolated ACL reconstruction. However, we could not identify significant differences between the two groups in terms of functional outcomes.

Functional outcome of implant-free bone-patellar tendon autograft versus hamstring autograft in arthroscopic anterior cruciate ligament reconstruction: A prospective study

Quadriceps Tendon: The Forgotten Graft

High failure rate of anterior cruciate ligament reconstruction with bimeniscal repair: A case-control study

Background: Meniscal allograft transplantation (MAT) is indicated in the setting of anterior cruciate ligament (ACL) reconstruction to restore proper arthrokinematics and load distribution for the meniscus-deficient knee. Objective outcomes after ACL reconstruction with concomitant MAT in athletic populations are scarcely reported and highly variable. Purpose: To compare patient outcomes using an objective functional performance battery, self-reported outcome measures, and return-to-sport rates between individuals undergoing ACL reconstruction with concomitant MAT and a matched group undergoing isolated ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: A single-surgeon ACL reconstruction database (N = 1431) was used to identify patients undergoing ACL reconstruction with concomitant MAT between 2014 and 2019. Patients were age-, sex-, and revision-matched to a group undergoing isolated ACL reconstruction. Baseline patient and surgical data were obtained. Patients completed an objective functional performance battery at the time of return to sport that included range of motion, single-leg squat performance, single-leg hop test performance, self-reported function (International Knee Documentation Committee [IKDC] score), and psychological readiness (ACL Return to Sports After Injury scale). Between-limb comparisons were assessed using limb symmetry indices. Injury surveillance was conducted for 2 years and included the Single Assessment Numeric Evaluation (SANE), reinjury rates, complications, and current level of sports participation. Between-group comparisons at the time of return to sport and 2 years later were analyzed using generalized linear models for parametric and nonparametric equivalents with an a priori alpha level of .05. Results: A total of 46 patients were included in the ACL reconstruction with concomitant MAT group (38 medial MAT, 8 lateral MAT), and 46 patients were included in the isolated ACL reconstruction group. Baseline differences existed between groups, with the MAT group exhibiting lower body weight (84.0 ± 14.1 vs 93.2 ± 191.8 kg; P = .036) and Marx scores (4.8 ± 4.5 vs 9.3 ± 4.1; P = .024) than the isolated ACL reconstruction group, respectively. At the time of return to sport, the MAT group reported lower IKDC scores (83.2 ± 12.6 vs 91.1 ± 11.3; P = .037); however, no other functional performance or self-reported differences were observed. At 2 years, no significant differences existed between groups for SANE score (87.8 ± 12.3 vs 89.3 ± 11.4; P = .793), ACL graft reinjury rates (6.5% vs 2.2%; P = .688), or level of return to sport (P > .05). The MAT group demonstrated a significantly lower rate of return to previous level of sport (69.5% vs 78.3%; P = .026). Conclusion: The majority of patients (87%) undergoing ACL reconstruction with concomitant MAT were able to return to some level of sports participation at 2 years with a low risk of revision ACL reconstruction or meniscal transplant failure. Patients receiving a concomitant MAT exhibited lower self-reported function at return to sport compared with matched controls undergoing isolated ACL reconstruction; however, these differences were not present at 2 years. Clinicians should consider patient characteristics, self-reported function, and return-to-sport rates when counseling patients regarding ACL reconstruction with MAT.

BackgroundCombined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injury is the most common combination of ligamentous knee injury. Many authors support the conservative treatment of MCL tears. This study aimed to compare the outcomes of simultaneous ACL reconstruction (ACL-R) and MCL reconstruction with ACL-R and conservative MCL treatment in cases of combined ACL and grade III MCL injuries.MethodsIn this retrospective cohort study, we evaluated consecutive patients with combined ACL and MCL injuries who underwent surgical treatment over five years in two private hospitals in Tehran, Iran. We compared postoperative knee range of motion (ROM), pain intensity (visual analog scale [VAS]), functional outcomes (Tegner-Lysholm and International Knee Documentation Committee Subjective Knee Form [IKDC] scores), time to and proportion of return to sports, time to return to work, activity level (Marx activity rating scale), and graft failure rate between ACL-R and conservative MCL treatment (ACL-R + conservative MCL group) and ACL-R and MCL reconstruction (ACL-R + MCL-R group). All patients were followed for at least twelve months.ResultsOverall, 110 patients, comprising 92 men (83.6%) and 18 women (16.4%), were included, consisting of 67 (60.9%) in the ACL-R + conservative MCL group and 43 (39.1%) in the ACL-R + MCL-R group. The mean age of the patients was 27.5 ± 9.0 years. Age, sex, side, and follow-up period were comparable between the groups (P > 0.05 for all). Graft failure occurred in 6 patients (9.0%) in the ACL-R + conservative MCL group, but in none of the patients in the ACL-R + MCL-R group (P = 0.046). Range of extension and flexion of the knee, VAS, Tegner-Lysholm score, IKDC score, time to return to sports, time to return to work, proportion of return to sports, and activity level did not differ significantly between the groups (P > 0.05 for all).ConclusionACL-R and MCL reconstruction resulted in similar knee ROM, pain intensity, functional outcomes, time to return to work and sports, and activity level to ACL-R and conservative MCL treatment in patients with combined ACL and MCL injury. However, ACL-R and MCL reconstruction significantly reduced graft failure rates, suggesting the potential benefit of surgical MCL management in conjunction with ACL reconstruction.

To retrospectively analyze the clinical efficacy of anterior cruciate ligament (ACL) reconstruction combined with anterolateral complex repair and ACL reconstruction combined with ALL reconstruction in the treatment of anterior cruciate ligament injuries with high-grade pivot shift. From January 2018 to June 2022, 49 patients combined ACL and ALL injuries with high-grade pivot shift were retrospectively studied from three hospitals, 29 of them underwent ACL reconstruction with anterolateral complex repair (repair group), including 23 males and 6 females with an average age of (27.5±4.8) years old, ranged from 20 to 37 years old;the injured sides were 13 on the left and 16 on the right, and 11 patients were suffered with meniscus injury. The other 20 patients underwent ACL and ALL reconstruction (reconstruction group) including 17 males and 3 females with the mean age of (27.1±4.5) years old, ranged from 20 to 38 years old;the injured sides were 8 on the left and 12 on the right, and 6 patients were suffered with meniscus injury. Knee stability (pivot shift test, KT-2000), range of motion, knee function (Lysholm scoring scale, Cincinnati sports activity scale (CSAS) scoring scale, and Tegner activity level score between two groups were compared. A total of 49 patients were followed up, the repair group receiving 13 to 20(15.3±1.8) months and the reconstruction group receiving 12 to 21(16.0±2.2) months. There was no statistically significant difference in the preoperative pivot shift test grading distribution between two groups (P>0.05). At the last postoperative follow-up, there were 24 patients with grade 0 and 5 patients with grade 1 in the repair group, and there were 18 patients with grade 0 and 2 patients with grade 1 in the reconstruction group, there is no significant difference in the distribution of axial shift test grading between two groups(P>0.05). The preoperative KT-2000 tibial displacement of two groups were (9.39±0.77) mm (repair group) and (9.14±0.78) mm (reconstruction group) respectively, with no statistically significant difference (P>0.05). At the final postoperative follow-up, there were 24 patients with KT-2000 tibial displacement <3 mm and 5 patients with 3 to 5 mm in the repair group, while 18 patients with <3 mm and 2 patients with 3 to 5 mm in the reconstruction group, KT-2000 tibial displacement distribution of two groups was no significant difference (P>0.05), but the KT-2000 tibial displacement in the reconstruction group (1.30±0.86) mm was significantly smaller than that in the repair group (1.99±1.11) mm (P<0.05). The final postoperative follow-up range of motion of the contralateral side knee between two groups was no significant difference (P>0.05). The range of motion of the suffering knee in the repair group was less than that in the reconstruction group (P<0.05). There was no significant difference in preoperative Lysholm and CSAS scores between two groups (P>0.05). At the final postoperative follow-up, both groups showed significant improvement in Lysholm and CSAS scores, while the Lysholm and CSAS scores of the reconstruction group were better than those of the repair group, and the difference was statistically significant (P<0.05). Significant differences was found in Tegner scores between two groups, which 16 patients in the repair group returned to their pre-injury activity level, and 17 patients in the reconstruction group returned to their pre-injury level (P<0.05). Compared to anterolateral complex repair, combined ACL and ALL reconstruction in the treatment of ACL injuries with high-grade pivot shift results in better knee joint function and stability. This is advantageous in reducing the risk of ACL reconstruction failure.

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Background: Anterior cruciate ligament (ACL) tear occurs between 29 to 38 cases per 100.000 people annually with more than half of cases requiring an ACL reconstruction. Peroneus longus tendon (PLT) has growing popularity as an autograft for ACL reconstruction providing comparable outcomes with proper graft diameter size, lack of donor site morbidity and uncomplicated harvesting technique. Unfortunately, certain studies did not agree with the superiority of PLT to the standard hamstring tendon (HT). Objective: The aim of study is to compare the knee functional outcome of an ACL reconstruction using peroneus longus and hamstring tendon according to recent publications. Methods: This study conducted a thorough systematic search for relevant scientific reports on multiple medical databases, including PubMed, Embase, and Google Scholar, using a combination of keywords such as "peroneus longus," “hamstring tendon,” "ACL reconstruction," “IKDC,” and “Lysholm”. The search was performed in April 2013-2023, resulting in 1567 studies. Two reviewers (RR, WA) independently screened the abstracts and reference lists, with any discrepancies resolved through consensus, concluding 5 included studies. Results: Five studies are included with a total of 538 patients consisting of 267 patients who underwent ACL reconstruction with PLT and 271 patients who underwent ACL reconstruction with HT. Up to 24 months follow-up, there are equally balanced satisfactory functional outcomes between ACL reconstruction using peroneus longus and hamstring tendon, in terms of IKDC (I2 = 74%; SMD = 0.08 95%CI, -0.21 to 0.38; p = 0.57) and Lysholm score (I2 = 75%; SMD = 0.06 95%CI, -0.27 to 0.39; p = 0.73). Conclusion: ACL reconstruction using the peroneus longus tendon is a safe and effective procedure with excellent short to long term functional outcome of the knee. Keywords: Anterior Cruciate Ligament Reconstruction, Functional Outcome, Hamstring tendon, Human, Peroneus Longus Tendon Keywords: Anterior Cruciate Ligament Reconstruction, Functional Outcome, Hamstring tendon, Human, Peroneus Longus Tendon.