REVIEW ARTICLE


https://doi.org/10.5005/jp-journals-10040-1320
Journal of Foot and Ankle Surgery (Asia-Pacific)
Volume 11 | Issue 1 | Year 2024

Harvesting Peroneus Longus Tendon for ACL Reconstruction: Impact on Ankle Functions and Biomechanics?


Ajoy S Manik1https://orcid.org/0000-0003-2553-6963, Rahul Panduranga2https://orcid.org/0000-0003-4057-2196, Prasoon Kumar3, Ronak N Kotian4https://orcid.org/0000-0001-9268-9674, Ramesh Debur5, Sushruth Jagadish6https://orcid.org/0000-0001-8127-7770, Vishal Patil7https://orcid.org/0000-0002-4226-9054

1,2,4Department of Orthopaedics, Ramaiah Medical College and Hospital (RMCH), Bengaluru, Karnataka, India

3Department of Orthopaedics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

5Department of Physiotherapy, Ramaiah Medical College and Hospital (RMCH) Bengaluru, Karnataka, India

6Department of Orthopaedics, Bangalore Medical College & Research Institute, Bengaluru, Karnataka, India

7Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India

Corresponding Author: Ronak N Kotian, Department of Orthopaedics, Ramaiah Medical College and Hospital (RMCH), Bengaluru, Karnataka, India, Phone: +91 9886140316, e-mail: ronak16kotian@gmail.com

Received: 24 April 2023; Accepted: 12 June 2023; Published on: 30 December 2023

ABSTRACT

Aim and background: The purpose of this review was to evaluate the available evidence on the effect of harvesting the peroneus longus tendon (PLT) for anterior cruciate ligament (ACL) reconstruction on ankle functions and biomechanics.

Materials and methods: A total of 17 studies of interest were included in this narrative review. There were two systematic reviews, and the remaining 15 were either case series or comparative studies.

Results: Current literature does not strongly recommend the usage of PLT as a primary graft choice, which is evident from the many conflicting conclusions noted among them.

Conclusion: There is a need to build the evidence with long-term studies that evaluate the objective assessment of ankle function, such as gait analysis, isokinetic muscle strength testing, and foot pressure studies after PLT harvest for ACL reconstruction. Alternatively, a multicentric study is required to recruit a large number of subjects to come to a true conclusion.

Clinical significance: The effect of harvesting PLT on the foot biomechanics has to be evaluated before it becomes a norm to utilize it as an autograft for ACL reconstruction. This review provides information regarding the current trend and discusses evidence behind the same.

How to cite this article: Manik AS, Panduranga R, Kumar P, et al. Harvesting Peroneus Longus Tendon for ACL Reconstruction: Impact on Ankle Functions and Biomechanics? J Foot Ankle Surg (Asia-Pacific) 2024;11(1):8–12.

Source of support: Nil

Conflict of interest: None

Keywords: Anterior cruciate ligament reconstruction, Ankle function, Biomechanics, Peroneus longus tendon

INTRODUCTION

Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed orthopedic procedures in the United States of America, with 100,000 to 175,000 annual reconstructions.1 The two most common autografts used for ACL reconstruction are bone patellar tendon-bone and hamstring autograft. Considerable attention has recently been focused on using peroneus longus tendon (PLT) autograft as an alternative to conventional autograft in the field of ACL reconstruction. Previously, the PLT autografts have been used in the reconstruction of acromioclavicular ligament,2 deltoid ligament,3 spring ligament,4 and medial patellofemoral ligament.5 However, questions remain as to whether harvesting PLT would result in donor site morbidity like ankle instability, loss of eversion power and obliteration of transverse arch.

There is a lack of comprehensive donor-site evaluation after PLT harvest, which is why PLT is not preferred.6 Therefore, the purpose of this article was to review existing evidence concerning the effect of harvesting PLT on ankle functions and biomechanics.

MATERIALS AND METHODS

Search Strategy

A PubMed search was performed on 21st May 2023 with mesh terms “peroneus” and “longus” and “grafts” or “grafted” or “graftings” or “grafts” (all fields) or “graft” (all fields). This yielded only 176 hits.

Further search specifically for ACL reconstruction with keywords; “peroneus” and “longus” and “grafts” or “grafted” or “graftings” or “grafting” or “grafts” or “graft” and “ACL” or “reconstruction” (all fields) or “reconstruction” or “reconstructs” yielded only 52 hits.

A third search to look into the associated donor site complications with keywords: “peroneus” and “longus” and “grafts” or “grafted” or “graftings” or “grafting” or “complications” yielded only 10 hits.

Selection of Studies (Inclusion and Exclusion Criteria)

Studies of any design in the English language discussing the usage and impact of PLT autografts for ACL reconstructions on ankle functions and overall altered biomechanics were included. Articles on animal data, conference abstracts, posters, case reports, book chapters, and studies describing graft usage in other surgeries were excluded.

Data Collection

All the hits were screened independently by two authors based on title and/or abstract for inclusion. The full text of all the screened articles was read, and the relevance was assessed. Discrepancies were resolved by discussions among the authors. A secondary search was also done from the bibliography list of all selected articles.

RESULTS

A total of 17 studies of interest were included in this narrative review. There were two systematic reviews, and the remaining 15 were either case series or comparative studies. All the included studies were published between 2014 and 2023, showing that PL autograft usage has increased in recent years for ACL reconstructions.

Multiple outcome evaluation tools have been utilized by researchers to evaluate the donor site morbidity following PL harvest, such as American Orthopedic Foot and Ankle Score (AOFAS) and Foot and Ankle Disability Index (FADI). In the biggest series of ACL reconstructions with the PL autografts, Hossain et al.7 reported their findings of single bundle arthroscopic surgeries in 439 patients at 2 years follow-up. Looking specifically at the donor site morbidity, they used AOFAS and FADI to assess ankle function and stability; additionally, they also evaluated the same by “hop” tests. The mean AOFAS score was 97.63, and the FADI score was 98.4. The mean cross-over hop test score was 94.2, while it was 94.2 for the timed hop test. Overall, the authors concluded that the PL graft for ACL reconstruction is an excellent choice with excellent residual ankle function.

Singh et al.8 used the PL graft as supplementation for inadequate hamstrings (<8 mm thickness or <7.5 cm length) in 30 cases of ACL reconstructions in patients with a mean age of 28.8 years. They utilized FADI, with a maximum score of 136, to evaluate the ankle stability; they found that the scores were all within the normal range and comparable to the preoperative index (135.8) at 6 months postoperatively without any complications.

On a similar pattern, Liu et al.9 also utilized the anterior portion of the PL tendon to reinforce unqualified four-strand hamstring grafts (mean diameter 6.2 mm), resulting in a mean diameter of 9.6, in eight patients; the authors found the FADI score for the donor side to be 135.8 with no complications.

Similar findings were reported by Sharma et al.,10 in 10 cases of ACL reconstructions with the PL graft, with mean AOFAS of 94.5 and FADI of 94.2% with minimal donor site morbidity and no significant alteration of ankle function at 1-year follow-up.

Another study by Keyhani et al.11 compared hamstring and PL grafts for ACL reconstructions in 130 patients (65 each); they also evaluated the impact of PL graft harvest on ankle function by assessing the AOFAS, FADI, and ankle range of motion (ROM). The ankle ROM was comparable to the normal side of the patients, with mean plantar flexion of 36.8° and eversion of 24.7°. The mean AOFAS was excellent (93.42), and the mean FADI score was 92.78 in comparison to 98.91 on the healthy side; the difference was not significant. There was no serious instability or complications noted in either group. In a study by Rajani et al.12 on 113 patients as well, the impact of PL harvest on the ankle was reported to be insignificant, with a FADI score of 94.8% with no clinical laxity at 3 years.

In a systematic review by Marin et al.,13 in which 6/12 included studies reported on the impact of PL harvesting on ankle morbidity and stability, the authors concluded that the ankle functional outcomes were favorable. Similarly, a study by Bi et al.14 utilizing only the anterior half of the PL tendon for ACL reconstructions in 62 cases of all inside single bundle reconstruction showed no ankle site complications and an average AOFAS score of 99.1 at a follow-up of 24 months.

Agarwal et al.15 published their results of PL grafting in 98 cases of ACL reconstructions and reported no obvious donor site morbidity with a mean AOFAS of 99.05. Joshi et al.16 also showed an excellent AOFAS score of 98.4 at 2 years in 48 patients of ACL reconstruction with PL graft, terming it a safe and effective graft option.

On the contrary, a systematic review and meta-analysis of 23 studies comparing PL grafts and hamstring grafts for ACL reconstructions reported inferior AOFAS in the PL group. However, the FADI scores were similar to the healthy side in these patients.17

In terms of muscle strength and biomechanics, Rhatomy et al.18 evaluated eversion and 1st ray plantar flexion in 31 patients of ACL reconstruction with PL graft; they used a modified dynamometer and found no significant difference in strength of ankle eversion (65.8 vs 66.9 N) or first ray plantar flexion in comparison to healthy side (150.6 vs 152.1 N) at 6 months postoperatively. The mean FADI was 99.7, and the mean AOFAS score was 98.7 on the donor sides.

Goyal et al.19 utilized the PL graft in 10 ACL revisions and found no detrimental effect on ankle ROMs, first ray plantar flexion using an isometer and the AOFAS score at 2 years, which were all comparable to the normal side.

Shao et al.,6 in their case series, used the square hop test as a functional performance test to evaluate whether or not there was any potential ankle instability during dynamic activity. For objective assessment, they measured the ankle ROM preoperatively and postoperatively, along with postoperative bilateral ankle strength (plantar flexion peak force and eversion peak force) for comparison. None of the above parameters examined was statistically significant except peak eversion force (p-value of <0.0001). The mean eversion strength deficit in their patient population was 8.5%, and they concluded that the deficit was not severe enough to affect ankle stability.

Shi et al.20 found no significant differences were observed in ankle dorsiflexion strength preoperatively (80.92 ± 0.26 N) and postoperatively (80.00 ± 0.57 N at 12 months and 81.46 ± 0.48 N at 24 months) of the PLT resected donor ankle.20 There were also no marked differences in ankle plantar flexion strength preoperatively (147.96 ± 0.38 N) and postoperatively (147.76 ± 0.25 N at 12 months and 150.22 ± 0.35 N at 24 months) of the donor’s ankle. Comparison of the loss of torque following tendon harvest two years following surgery was not found to be statistically significant when compared to the contralateral ankle.

On the contrary, Angthong et al.21 studied the donor site complications in 24 patients undergoing ACL reconstructions with the PL grafts and found that at 7 months postsurgery, peak torques of inversion, as well as eversion, were lower significantly (60°/second and 120°/second, p < 0.05) in comparison to the healthy side when isokinetic testing was done in 10 of the 24 patients. However, the mean AOFAS was similar to the preoperative values in all patients (100 vs 96). The authors concluded that these patients strongly need strengthening exercises for the ankle eversion, including proprioceptive exercise, to prevent ankle instability owing to the potential evertor weakness, particularly within the first 12 months of surgery.

The possible effects of harvesting the PLT on gait parameters have been studied by Nazem et al.22 They utilized a “Kistler force plate” to detect three-dimensional kinematics and kinetics of the ankles and spatiotemporal walking parameters like stride length, speed, and cadence. No statistically significant difference in the mean values of spatiotemporal gait parameters between operated and nonoperated sides (p > 0.05) was observed. They concluded that removal of the PLT had no or minimal effect on gait parameters and would not lead to ankle instability.

Overall, there seems to be an insignificant impact of PL tendon graft harvest on the donor’s ankle, with function and stability not impacted. Occasional reports of reduction in AOFAS score within the 1st year of surgery have been described, but in the long-term, there seem to be no clinical/functional complications (Figs 123).

Fig. 1: Length of the peroneus longus tendon after harvest

Fig. 2: Length of the tripled peroneus longus tendon

Fig. 3: Diameter of the tripled peroneus longus tendon

DISCUSSION

A multitude of studies have attributed PLT as a promising new graft for ACL reconstruction, and it has various beneficial characteristics (Table 1). Full or partial-thickness PLT harvesting has been routinely performed by some orthopedic surgeons due to its size and easy harvesting technique.23,25 The functional outcomes were comparable in ACL reconstruction using the PLT versus the hamstring tendon, with PLT having the advantages of larger graft diameter, less thigh hypotrophy and excellent ankle function.18 Normal ACL strength has been reported to be 1725 ± 269 N26 whereas the PLT strength was 1950 N as described by Kerimoglu et al.27 Also, hamstrings had a lower average tensile strength value compared to the PLT without significant difference (p > 0.05) and their biomechanical properties were comparable.28

Table 1: The advantages and disadvantages of peroneus longus tendon as an autograft for anterior cruciate ligament reconstruction
Advantages Disadvantages
Thicker graft diameter Eversion weakness
Larger length Lateral ankle instability
Easy harvesting technique Obliteration of arches of the foot
Higher tensile strength First ray plantar flexion weakness

The PLT plays a versatile role in the foot and ankle.29,30 Although its major action is to cause first-ray plantarflexion and to evert the foot, it also has a role in maintaining the transverse arch.29-31 One major concern after PLT harvest is the impairment of ankle plantar flexion and eversion strength. Ankle stability remains intact only if ankle strength remains adequate.32 Also, a 22% deficit of eversion strength was noted in the population who had ankle instability.33,34 However, recent studies have demonstrated that a modest decrease in muscle strength does not affect ankle function drastically.6

It is very well known that <4% of total ankle plantarflexion strength is contributed by peroneus longus, and the gastrocnemius-soleus complex contributed up to 87%.34,35 Interestingly, only 35% of ankle eversion strength is provided by peroneus longus, while the rest of eversion strength is contributed by peroneus brevis, peroneus tertius, extensor hallucislongus and extensor digitorum longus.35,36 Therefore, it is likely that related adjoining muscles of the leg “take over” some function of the peroneus longus, and harvesting PLT would not result in significant ankle instability or eversion weakness.6

The regeneration of PLT after harvesting has been well documented.6,21,27 Histological studies resonate the same.37,38 MRI has been used to evaluate the signals analogous to PBT in the location of normal PLT as findings indicative of probable tendon regeneration.27,39-42 Therefore, it is likely that a variable degree of tendon regeneration took place after the PLT harvest and might be one of the reasons why the PLT harvest did not lead to significant ankle instability.6 Furthermore, age was correlated negatively to PLT regeneration and hence younger patients better the ability to regenerate.6,43,44

Another point of major concern of donor-site morbidity was inherent damage to the arches of the foot, particularly the transverse arch and medial longitudinal arch.6 The importance of PLT in maintaining the arch of the foot has been demonstrated.35,45 However, a recent study46 evaluated a weight-bearing computed tomography scan of the foot and demonstrated the effect the PLT activation has on the medial longitudinal arch on unloaded and axially loaded cadaver legs. They found that PLT activation during stance caused a nonsignificant increase in Meary’s angle (p = 0.52), and reconstitution of the arch did not occur on weight-bearing.46 They concluded that the role of PLT in maintaining the longitudinal arch during stance is questionable and that further investigation is required in this direction to evaluate PLT as a dynamic stabilizer of the arch.46 Therefore, it is unclear whether harvesting PLT affects the arches of the foot and alters its integrity.

The study by Angthong et al.21 was the first study, to the best of our knowledge, to evaluate the isokinetic muscle strength testing of the donor’s ankle. They evaluated the donor ankle 6–7 months after the harvest and found significant deterioration of eversion and inversion strength at both velocities. On the contrary, Shi et al.20 did not find a statistically significant difference in the amount of torque lost during eversion and inversion after tendon harvesting or compared with the nondonor. The authors concluded that no obvious functional impairment occurred after harvesting the PLT to reconstruct the ACL in the donor’s ankle.

The PLT has a complex action and effect on the foot and ankle. We believe that eversion weakness, lateral ankle instability, obliteration of arches of the foot, adaptive shortening of muscle and neural inhibition are the possible manifestation of harvesting PLT, and its effect on ankle biomechanics has to be evaluated with validated objective assessment tools. Therefore, there is a need for a long-term study with a proper study design that would investigate the isokinetic muscle strength of the donor ankle as well as evaluation of the medial arch of foot-on-foot pressure studies and gait analysis to reach a true conclusion.

CONCLUSION

After a review of the literature about the harvest of the PLT for ACL reconstruction, it is evident that the final word on the safety and efficacy is not out yet. Many studies have mentioned that there is no loss of strength or instability following the harvest but have not used validated outcome measures for the evaluation. We would need a long-term study with proper study design along with analysis of medial arch of the foot-on-foot pressure studies and gait analysis to reach a true conclusion which is currently underway at our institution, the results of which would be out in a couple of years from now.

Clinical Significance

The effect of harvesting PLT on the foot biomechanics has to be evaluated before it becomes a norm to utilize it as an autograft for ACL reconstruction. This review provides information regarding the current trend and discusses evidence behind the same.

ORCID

Ajoy S Manik https://orcid.org/0000-0003-2553-6963

Rahul Panduranga https://orcid.org/0000-0003-4057-2196

Ronak N Kotian https://orcid.org/0000-0001-9268-9674

Sushruth Jagadish https://orcid.org/0000-0001-8127-7770

Vishal Patil https://orcid.org/0000-0002-4226-9054

REFERENCES

1. Mall NA, Chalmers PN, Moric M, et al. Incidence and trends of anterior cruciate ligament reconstruction in the United States. Am J Sports Med 2014;42(10):2363–2370. DOI: 10.1177/0363546514542796

2. Zhu Y, Hsueh P, Zeng B, et al. A prospective study of coracoclavicular ligament reconstruction with autogenous peroneus longus tendon for acromioclavicular joint dislocations. J Shoulder Elbow Surg 2018;27(6):e178–e188. DOI: 10.1016/j.jse.2017.12.009

3. Ellis SJ, Williams BR, Wagshul AD, et al. Deltoid ligament reconstruction with peroneus longus autograft in flatfoot deformity. Foot Ankle Int 2010;31(9):781–789. DOI: 10.3113/FAI.2010.0781

4. Williams BR, Ellis SJ, Deyer TW, et al. Reconstruction of the spring ligament using a peroneus longus autograft tendon transfer. Foot Ankle Int 2010;31(7):567–577. DOI: 10.3113/FAI.2010.0567

5. Xu C, Zhao J, Xie G. Medial patella-femoral ligament reconstruction using the anterior half of the peroneus longus tendon as a combined procedure for recurrent patellar instability. Asia Pac J Sports Med Arthrosc Rehabil Technol 2016;4:21–26. DOI: 10.1016/j.asmart.2016.03.001

6. Shao X, Shi LL, Bluman EM, et al. Satisfactory functional and MRI outcomes at the foot and ankle following harvesting of full thickness peroneus longus tendon graft. Bone Joint J 2020;102-B(2):205–211. DOI: 10.1302/0301-620X.102B2.BJJ-2019-0949.R1

7. Hossain GMJ, Islam MS, Rahman Khan MM, et al. A prospective study of arthroscopic primary ACL reconstruction with ipsilateral peroneus longus tendon graft: experience of 439 cases. Medicine (Baltimore) 2023;102(9):e32943. DOI: 10.1097/MD.0000000000032943

8. Singh H, Agarwal KK, Tyagi S, et al. A study of the functional outcome of supplementation of hamstring graft with anterior half of the peroneus longus tendon in arthroscopic anterior cruciate ligament reconstruction. Cureus 2022;14(10):e30138. DOI: 10.7759/cureus.30138

9. Liu CT, Lu YC, Huang CH. Half-peroneus-longus-tendon graft augmentation for unqualified hamstring tendon graft of anterior cruciate ligament reconstruction. J Orthop Sci 2015;20(5):854–860. DOI: 10.1007/s00776-015-0744-2

10. Sharma D, Agarwal A, Shah K, et al. Peroneus longus: most promising autograft for arthroscopic ACL reconstruction. Indian J Orthop Surg 2019;5(3):172–175. DOI: 10.18231/j.ijos.2019.033

11. Keyhani S, Qoreishi M, Mousavi M, et al. Peroneus longus tendon autograft versus hamstring tendon autograft in anterior cruciate ligament reconstruction: a comparative study with a mean follow-up of two years. Arch Bone Jt Surg 2022;10(8):695–701. DOI: 10.22038/ABJS.2022.59568.2938

12. Rajani AM, Shah UA, Mittal AR, et al. Functional and clinical outcome of anterior cruciate ligament reconstruction with peroneus longus autograft and correlation with MRI after 3 years. J Orthop 2022;34:215–220. DOI: 10.1016/j.jor.2022.08.027

13. Marín Fermín T, Hovsepian JM, Symeonidis PD, et al. Insufficient evidence to support peroneus longus tendon over other autografts for primary anterior cruciate ligament reconstruction: a systematic review. J ISAKOS 2021;6(3):161–169. DOI: 10.1136/jisakos-2020-000501

14. Bi M, Zhao C, Zhang S, et al. All-inside single-bundle reconstruction of the anterior cruciate ligament with the anterior half of the peroneus longus tendon compared to the semitendinosus tendon: a two-year follow-up study. J Knee Surg 2018;31(10):1022–1030. DOI: 10.1055/s-0038-1627466

15. Agarwal A, Singh S, Singh A, et al. Comparison of functional outcomes of an anterior cruciate ligament (ACL) reconstruction using a peroneus longus graft as an alternative to the hamstring tendon graft. Cureus 2023;15(4):e37273. DOI: 10.7759/cureus.37273

16. Joshi S, Shetty UC, Salim MD, et al. Peroneus longus tendon autograft for anterior cruciate ligament reconstruction: a safe and effective alternative in nonathletic patients. Niger J Surg 2021;27(1):42–47. DOI: 10.4103/njs.NJS_22_20

17. He J, Tang Q, Ernst S, et al. Peroneus longus tendon autograft has functional outcomes comparable to hamstring tendon autograft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2021;29(9):2869–2879. DOI: 10.1007/s00167-020-06279-9

18. Rhatomy S, Wicaksono FH, Soekarno NR, et al. Eversion and first ray plantarflexion muscle strength in anterior cruciate ligament reconstruction using a peroneus longus tendon graft. Orthop J Sports Med 2019;7(9):2325967119872462. DOI:10.1177/2325967119872462

19. Goyal T, Paul S, Choudhury AK, et al. Full-thickness peroneus longus tendon autograft for anterior cruciate reconstruction in multi-ligament injury and revision cases: outcomes and donor site morbidity. Eur J Orthop Surg Traumatol 2023;33(1):21–27. DOI: 10.1007/s00590-021-03145-3

20. Shi FD, Hess DE, Zuo JZ, et al. Peroneus longus tendon autograft is a safe and effective alternative for anterior cruciate ligament reconstruction. J Knee Surg 2019;32(8):804–811. DOI: 10.1055/s-0038-1669951

21. Angthong C, Chernchujit B, Apivatgaroon A, et al. The anterior cruciate ligament reconstruction with the peroneus longus tendon: a biomechanical and clinical evaluation of the donor ankle morbidity. J Med Assoc Thai 2015;98(6):555–560.

22. Nazem K, Barzegar M, Hosseini A, et al. Can we use peroneus longus in addition to hamstring tendons for anterior cruciate ligament reconstruction? Adv Biomed Res 2014;3:115. DOI: 10.4103/2277-9175.132696

23. Zhao J, Huangfu X. The biomechanical and clinical application of using the anterior half of the peroneus longus tendon as an autograft source. Am J Sports Med 2012;40(3):662–671. DOI:10.1177/0363546511428782

24. Cao HB, Liang J, Xin JY. Treatment of anterior cruciate ligament injury with peroneus longus tendon. Zhonghua Yi Xue Za Zhi 2012;92(35):2460–2462.

25. Kim HN, Jeon JY, Dong Q, et al. Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon. Knee Surg Sports Traumatol Arthrosc 2015;23(6):1877–1885. DOI: 10.1007/s00167-014-3072-8

26. Caplan N, Kader DF. Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. Classic Papers Orthop 2014;145–147. DOI: 10.1007/978-1-4471-5451-8_35

27. Kerimoğlu S, Koşucu P, Livaoğlu M, et al. Magnetic resonance imagination of the peroneus longus tendon after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2009;17(1):35–39. DOI: 10.1007/s00167-008-0626-7

28. Mustamsir E, Phatama KY. Tensile strength comparison between peroneus longus and hamstring tendons: a biomechanical study. Int J Surg Open 2017;9:41–44. DOI: 10.1016/j.ijso.2017.10.002

29. Jacob HA. Forces acting in the forefoot during normal gait–an estimate. Clin Biomech (Bristol, Avon) 2001;16(9):783–792. DOI:10.1016/s0268-0033(01)00070-5

30. Ferris L, Sharkey NA, Smith TS, et al. Influence of extrinsic plantar flexors on forefoot loading during heel rise. Foot Ankle Int 1995;16(8):464–473. DOI: 10.1177/107110079501600802

31. O’Connor KM, Hamill J. The role of selected extrinsic foot muscles during running. Clin Biomech (Bristol, Avon) 2004;19(1):71–77. DOI: 10.1016/j.clinbiomech.2003.09.001

32. Maffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop Surg 2008;16(10):608–615. DOI:10.5435/00124635-200810000-00006

33. Arnold BL, Linens SW, De La Motte SJ, et al. Concentric evertor strength differences and functional ankle instability: a meta-analysis. J Athletic Training 2009;44(6):653–662. DOI: 10.4085/1062-6050-44.6.653

34. Donnelly L, Donovan L, Hart JM, et al. Eversion strength and surface electromyography measures with and without chronic ankle instability measured in 2 positions. Foot Ankle Int 2017;38(7):769–778. DOI: 10.1177/1071100717701231

35. Selmani E, Gjata V, Gjika E. Current concepts review: peroneal tendon disorders. Foot Ankle Int 2006;27(3):221–228. DOI:10.1177/107110070602700314

36. Perry J. Anatomy and biomechanics of the hindfoot. Clin Orthop Relat Res 1983(177):9–15.

37. Ferretti A, Conteduca F, Morelli F, et al. Regeneration of the semitendinosus tendon after its use in anterior cruciate ligament reconstruction: a histologic study of three cases. Am J Sports Med 2002;30(2):204–207. DOI: 10.1177/03635465020300021001

38. Lu CC, Zhang T, Reisdorf RL, et al. Biological analysis of flexor tendon repair-failure stump tissue: A potential recycling of tissue for tendon regeneration. Bone Joint Res 2019;8(6):232–245. DOI: 10.1302/2046-3758.86.BJR-2018-0239.R1

39. Konrath JM, Vertullo CJ, Kennedy BA, et al. Morphologic characteristics and strength of the hamstring muscles remain altered at 2 years after use of a hamstring tendon graft in anterior cruciate ligament reconstruction. Am J Sports Med 2016;44(10):2589–2598. DOI: 10.1177/0363546516651441

40. Choi JY, Ha JK, Kim YW, et al. Relationships among tendon regeneration on MRI, flexor strength, and functional performance after anterior cruciate ligament reconstruction with hamstring autograft. Am J Sports Med 2012;40(1):152–162. DOI: 10.1177/0363546511424134

41. Rispoli DM, Sanders TG, Miller MD, et al. Magnetic resonance imaging at different time periods following hamstring harvest for anterior cruciate ligament reconstruction. Arthroscopy 2001;17(1):2–8. DOI: 10.1053/jars.2001.19460

42. Burks RT, Crim J, Fink BP, et al. The effects of semitendinosus and gracilis harvest in anterior cruciate ligament reconstruction. Arthroscopy 2005;21(10):1177–1185. DOI: 10.1016/j.arthro.2005.07.005

43. Klatte-Schulz F, Pauly S, Scheibel M, et al. Influence of age on the cell biological characteristics and the stimulation potential of male human tenocyte-like cells. Eur Cell Mater 2012;24:74–89. DOI: 10.22203/ecm.v024a06

44. Zhou Z, Akinbiyi T, Xu L, et al. Tendon-derived stem/progenitor cell aging: defective self-renewal and altered fate. Aging Cell 2010;9(5):911–915. DOI: 10.1111/j.1474-9726.2010.00598.x

45. Kokubo T, Hashimoto T, Nagura T, et al. Effect of the posterior tibial and peroneal longus on the mechanical properties of the foot arch. Foot Ankle Int 2012;33(4):320–5. DOI: 10.3113/FAI.2012.0320

46. Dullaert K, Hagen J, Klos K, et al. The influence of the peroneus longus muscle on the foot under axial loading: a CT evaluated dynamic cadaveric model study. Clin Biomech (Bristol, Avon) 2016;34:7–11. DOI: 10.1016/j.clinbiomech.2016.03.001

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