Inframalleolar harvest of the peroneus longus tendon graft: Surgical technique

Peroneus longus tendon (PLT) graft has recently gained visibility in the literature as a promising option for knee ligament reconstructions. The most used harvesting technique is performed with a single incision posterior to the lateral malleolus, with large series reporting tendon lengths enough to prepare a double or triple anterior cruciate ligament (ACL) graft, resulting in mean diameters greater than 8.0 mm. However, as happens with the hamstrings, some patients may present PLT grafts with a 7-mm diameter, which is associated with higher failure rates and is the minimum acceptable diameter for ACL reconstructions. In turn, the 2-incision technique has longer graft lengths reported, enough to prepare 4-folded grafts, with mean diameters above 9.0 mm, ranging from 8.5 to 10 mm. Once the PLT graft diameter has a direct correlation with anthropometric measurements, as well as larger ACL graft diameters are associated with lower failure rates and revision surgeries, the inframalleolar harvesting seems to be a reasonable option, especially for short-stature patients with a greater risk of insufficient grafts. Additionally, patients who benefit from an extra-articular procedure can have a combined reconstruction of the ACL and anterolateral ligament using the PLT graft with the two-incision technique, with no need for another graft. Therefore, this article aims to describe the step-by-step technique for the inframalleolar PLT harvesting.