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Article

Comparative Analysis of the Six-Strand Hamstring and Peroneus Longus in Sports Medicine and Rehabilitation

by
Ondar Artysh Vyacheslavovich
1,
Nikonova Alina Vladimirovna
1,
Dzhunusov Bekzhan
1,
Khaizhok Konstantin Ivanovich
1,
Evgeniy Goncharov
2,
Oleg Koval
2,
Eduard Bezuglov
3,
Manuel De Jesus Encarnacion Ramirez
4,* and
Nicola Montemurro
5,*
1
JSC Group Hospital MEDSI, 123056 Moscow, Russia
2
2nd National Clinical Centre of Federal State Budgetary Research Institution Russian Research Center of Surgery Named after Academician B.V. Petrovsky, 121359 Moscow, Russia
3
High Performance Sports Laboratory, Department of Sports Medicine and Medical Rehabilitation, Sechenov First Moscow State Medical University, 119991 Moscow, Russia
4
Neurological Surgery, Peoples Friendship University of Russia, 103274 Moscow, Russia
5
Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), 56100 Pisa, Italy
*
Authors to whom correspondence should be addressed.
Surgeries 2024, 5(3), 778-798; https://doi.org/10.3390/surgeries5030063
Submission received: 19 July 2024 / Revised: 17 August 2024 / Accepted: 30 August 2024 / Published: 6 September 2024
Browse Figures
Versions Notes

Abstract

:
The anterior cruciate ligament (ACL) is crucial for knee stability and is often injured in sports, leading to significant issues like degenerative changes and meniscal tears. ACL tears are prevalent in high-school sports injuries, accounting for 50% of knee injuries in the U.S. Surgical reconstruction, often involving bone-patellar tendon-bone (BPTB) or hamstring autografts, is common, with varying success rates and complications. Emerging alternatives like the peroneus longus tendon show promise but require further comparative studies. This prospective and multicentric study included 110 patients who underwent ACL reconstruction from 2020 to 2022. Fifty-five patients received hamstring tendon autografts (Group H) and fifty-five received peroneus longus tendon autografts (Group P). Surgeries were performed by experienced surgeons using standardized techniques. Patients were evaluated using clinical tests and functional scores including the Lysholm Knee Questionnaire and IKDC-2000 at various postoperative intervals up to 24 months. Data were analyzed using SPSS with a significance level set at p < 0.05. Group H showed superior knee function preoperatively and at 24 months postoperatively compared to Group P. Group H had higher Lysholm and IKDC scores consistently throughout the study period. The anterior drawer and Lachman’s tests indicated better knee stability for Group H. Complications were comparable between groups, with specific issues related to donor site morbidity and muscle weakness observed in each. The six-strand hamstring tendon autograft (Group H) demonstrated superior functional outcomes and knee stability compared to the peroneus longus tendon autograft (Group P) for ACL reconstruction. Despite some donor site morbidity, the hamstring tendon showed better long-term recovery and fewer complications. Future studies should explore larger, multicentric cohorts and integrate regenerative medicine techniques to further enhance ACL reconstruction outcomes.

1. Introduction

The anterior cruciate ligament (ACL) is the most frequently injured ligament of the knee, playing a crucial role in maintaining the stability of the knee joint. An ACL tear often leads to degenerative changes and increases the risk of meniscal injuries. The ACL, one of two cruciate ligaments, extends from the anteromedial aspect of the tibial plateau to the lateral femoral condyle, consisting of connective and collagenous fibers [1,2].
In the United States, knee injuries account for approximately 60% of high-school sports injuries, which are eventually surgically managed [3,4]. ACL tears account for more than 50% of knee injuries [5]. These have plagued numerous sportsmen and sportswomen, contributing to as many as 80% of all sports injuries [6,7]. This potentially causes further recurrent knee injuries, resulting in many not being able to return to preinjury levels [8]. For individuals not involved in sports, an ACL tear may contribute to premature osteoarthritis [9,10]. For patients who undergo surgical management of their ACL tear, the risk of early-onset osteoarthritis remains [11]. In the United States, USD1 billion is spent on ACL reconstruction [12]. The injury itself is painful and disabling [13].
Post-injury, individuals face an increased likelihood of degenerative changes such as osteoarthritis and are more prone to subsequent meniscal tears. These secondary injuries can further degrade joint integrity, leading to chronic pain and instability, which under-scores the importance of prevention strategies and advancements in treatment protocols to preserve knee function and enhance recovery outcomes.
ACL injuries are associated with, for example, a sevenfold increase in the odds of end-stage osteoarthritis resulting in total knee arthroplasties [14], more than USD90,000 per injury to gain a quality-adjusted life-year [15], and psychological barriers that may affect recovery, return to sport, and an increased risk of sustaining a subsequent injury [16].
ACL reconstruction is primarily performed using a variety of grafts including autografts and allografts to restore knee stability and function. Commonly utilized autografts include the bone-patellar tendon-bone (BPTB) and four-strand hamstring autografts, each with distinct benefits and drawbacks. Recent research has highlighted the BPTB graft as superior due to its bone-to-bone healing capabilities, which facilitate the integration of the graft and tunnel, thereby accelerating recovery and return to sports activities. This feature is particularly beneficial for professional athletes who have sustained ACL injuries. Despite its advantages, the BPTB graft is associated with several complications such as patellar fractures, large incision requirements, and increased risks of anterior kneeling pain, which are significant concerns, especially in cultures where pain-free kneeling is valued such as among Indian populations [17]. In contrast, the hamstring autograft, favored for its strength comparable to the native ACL and minimal donor site morbidity, is popular in Asian communities. However, it does present challenges including variable graft sizes and potential reduction in hamstring muscle strength, a crucial attribute for athletes relying on strong hamstrings for performance.
Innovatively, some orthopedic surgeons are exploring the use of the peroneus longus tendon as an alternative graft option. This tendon is also employed in other reconstructive procedures, such as those for the medial patellofemoral ligament (MPFL) and the spring ligament, thanks to the cooperative function of the peroneus longus and brevis muscles. Although the peroneus brevis is recognized as a potent ankle evertor, enhancing the ap-peal of harvesting the longus tendon, there are contrasting opinions about its efficacy due to concerns over donor-site morbidity [18,19]. Research indicates no significant difference in tensile strength between the hamstring and peroneus longus tendons, highlighting the need for further comparative studies on their functional outcomes in ACL reconstruction [20].

2. Materials and Methods

2.1. Patient Selection

This prospective, multicentric, and comparative controlled study was conducted between 2020 and 2022. The study included a total of 110 patients who underwent arthroscopic reconstruction of the anterior cruciate ligament (ACL). Among them, 55 patients were assigned to main group 1 (Group H) and received an autograft harvested from the peroneus longus tendon, while 55 patients were assigned to group 2 (Group P) and received a peroneus longus graft. The surgical procedures were carried out by three experienced surgeons from the traumatology and orthopedics department, each with over 5 years of experience and performing a minimum of 400 ACL reconstructions per year.
The surgical technique, instruments, and disposables were standardized and consistent across both groups. Only autografts were used for ACL reconstruction, with no utilization of allo- or xenografts or repair techniques. Suture techniques were employed to repair distinct types of meniscal tears including traumatic, ‘fresh’ para-capsular, longitudinal, and bucket handle tears in the red-red zone. A partial meniscectomy was performed for degenerative or flap-type meniscal tears in areas with poor blood supply.
The study was undertaken after obtaining the institute’s ethical committee approval. The cases were selected based on the following inclusion and exclusion criteria.
Inclusion criteria were clinical/MRI evidence of symptomatic individuals with anterior cruciate ligament insufficiency, patients between the ages of 18 to 60 years (skeletally matured patients), no history of previous surgery in the knee, and a normal contralateral knee. Exclusion criteria were asymptomatic individuals, patients with systemic diseases compromising their pre-anesthetic fitness, associated with PCL tear or associated Grade III MCL and LCL injuries, patients with osteoarthritic knee/cartilage injury, patients with associated fracture of the tibial plateau, patients with local skin infections, and patients unwilling to provide consent.
Evaluation of knee joint function involved the use of multiple assessment methods. Anamnesis encompassed information on the mechanism of injury, previous conservative treatments and rehabilitation, and the type of sports activity. Clinical examination included tests such as the anterior drawer test, pivot-shift test, Lachman test, range of motion assessment test, a. Additionally, at the 2-year follow-up, tests included the Lysholm Knee Questionnaire, IKDC-2000, and American Orthopedic Foot and Ankle Society (AOFAS) (main group only). Patient follow-up as well as pre- and postoperative examinations were conducted by the operating surgeons.
Cohen’s d was calculated to determine the effect size for key outcome measures, providing a standardized measure of the magnitude of differences between the two groups as follows:
Lysholm score: Cohen’s d was 0.55, indicating a moderate effect size, with the hamstring group demonstrating superior knee function over time.
IKDC score: Cohen’s d was 0.65, also reflecting a moderate effect size, suggesting that the hamstring group had significantly better overall knee health.
Anterior drawer test (Grade 0): Cohen’s d was 0.25, a small to moderate effect size, favoring the hamstring group in achieving normal anterior knee stability.
Lachman’s test (Grade 0): Cohen’s d was 0.20, indicating a small effect size in favor of the hamstring group.
Pivot shift test (Grade 0): Cohen’s d was −0.10, a small effect size slightly favoring the peroneus longus group, although this difference was minimal.
Ethical approval for the study was obtained from the local Academician B. V. Petrovsky (Moscow, Russia) ethics committee in 2022, with protocol number 11.

2.2. Surgical Technique

In both groups, ACL reconstruction was preceded by diagnostic and therapeutic arthroscopy that included partial meniscectomy/meniscal repair if it was necessary, resection of the hypertrophic synovial plica, and preparation for bone tunnel formation. In the next step, the autograft was harvested, and ACL reconstruction was performed.
In the peroneus longus group, the single-bundle technique was used, with an anteromedial portal for tunnel formation. The autograft was harvested from the peroneus longus tendon of the ipsilateral leg. The diameter of the bone tunnels was determined by the diameter of the graft. The graft was fixed with biodegradable interference screws (a blend of polylactic acid and hydroxyapatite). The screw diameter equaled the tunnel size; the length of the femoral and tibial interference fixators was 25 mm and 30 mm, respectively.
The course of the peroneus longus tendon was determined by putting the foot in the inverted position; then, a 2 cm skin incision was made along the PLT course over the posterior edge of the lateral malleolus. The skin incision was extended proximally and distally along the course of the tendon. The fascia was dissected, and the PLT was exposed and grasped using Billroth’s forceps and a dissector.
The autograft was harvested in the ventral direction using a blunt-tipped instrument to avoid injury to the adjacent anatomical structures including the sural nerve. The PLT lies superficial to the peroneus brevis tendon. At the donor site, the peroneus brevis tendon is thin and has clearly visible, prominent muscle tissue. This helps to differentiate between peroneus tendons and avoid surgical errors before the suturing step.
After the PLT was isolated, its proximal end (25 mm) was sutured using Krackow stitches, whereas its distal end was sutured using a biodegradable suture material (Figure 1A). Then, the tendon was transected between the suture sites. Its distal end was sutured to the tendinous portion of the peroneus brevis tendon. The proximal portion of the PLT was released from its muscular attachments using a stripper, and the autograft was harvested (Figure 1B).
The fascia was closed with absorbable sutures; the skin incision was closed with a nonabsorbable suture material. Once the graft was harvested, it was prepared for further implantation by the surgeon’s assistant. Briefly, the tendon was cleared of muscle fibers, the graft was folded in two, and its distal ends were secured to the graft preparation station. The unsutured distal end of the graft (25 mm) was sutured using Krackow stitches. The proximal end (25 mm) was sutured using a biodegradable suture. Then, the diameter of the graft was measured using a graft sizer tool.

2.3. Hamstring Graft

To prepare a 6-strand hamstring tendon graft, the semitendinosus and gracilis tendons are tripled. The proximal end of the gracilis tendon is whip-stitched with a suture, compressing and removing slack through a “cinching” motion. The tendon length is measured, requiring a minimum of 230 mm for tripling. The semitendinosus tendon is cut 8–10 mm longer than the gracilis and similarly whip-stitched.
The tendons are then tied to a polyester loop implant, connecting them for additional strength. The grafts are individually tripled as for a 6-strand graft, with the distal ends passed through the polyester loop (Ethibond, Arthrex, Naples, FL, USA) to bury connecting knots and reduce bulk. The combined tripled tendons form a 6-stranded graft (Figure 2).
Two equal-length tape loops are created by tying the ends of Dacron tape at specified points. The untied sutures on each tendon can be used for supplemental tibial fixation if needed. During final tensioning and tibial fixation, equal tension is applied to the graft strands using a graft tension device. The graft diameter is measured, pretensioned to 10 lbs, and wrapped with a “vancomycin wrap”.
While the graft was being prepared, the surgeon was forming bone tunnels as described above. Once ready, the graft was passed through the bone tunnels and fixed with biodegradable screws. The surgical technique used in the control group was the same as in the main group. The autograft for ACL reconstruction was a bone-patellar tendon-bone graft. Bone tunnels were 10 mm in diameter. The graft was fixed with biodegradable interference screws (a blend of polylactic acid and hydroxyapatite) of various lengths: 8 × 25 mm for the femoral tunnel and 8 × 30 mm for the tibial tunnel.

2.4. Postoperative Care and Rehabilitation

The postoperative care protocol was standardized for both groups. Patients did not wear braces during the early postoperative period. Weight-bearing on the operated leg, walking, and painless knee flexion and extension exercises were initiated as early as the day following surgery. Patients were advised to take three weeks off work and rest at home before gradually resuming their daily activities. By the sixth week, both groups achieved a minimum knee joint flexion angle of 90 degrees. For patients with meniscal sutures, knee flexion beyond 90 degrees was restricted for six weeks. Starting from the third month, patients were allowed to engage in gym workouts and run on a flat surface with straight-line tracks, avoiding sharp turns.
The protocol included the following key recommendations:
  • Early mobilization: Patients were encouraged to begin weight-bearing and knee flexion exercises starting the day after surgery. The goal was to achieve a minimum knee flexion angle of 90 degrees by the sixth week postoperatively.
  • Rehabilitation program: A structured rehabilitation program was implemented for all patients. This program focused on quadriceps and hamstring strengthening exercises, stationary cycling, and a gradual return to sports activities. The exercises were tailored to enhance muscle strength, improve joint flexibility, and support the overall recovery process.
  • Physical therapy: Patients were advised to avoid activities that could place undue strain on the graft, such as sharp turns or high-impact sports, until their recovery was sufficiently advanced. The rehabilitation plans included specific exercises to restore their full range of motion and strength while protecting the surgical site.
  • Return to sports: A cautious return to sports activities was recommended around six months postoperatively, once full recovery of muscle strength and knee stability had been achieved. For high-impact activities, knee band support was advised for up to one year to provide additional protection.
The postoperative care and rehabilitation of patients were closely supervised by the operating surgeons. Return to preoperative physical activity levels was recommended after the complete recovery of femoral and tibial muscles, which typically took an average of eight months. Follow-up examinations were conducted at 3, 6, 12, and 24 months post-surgery (Table 1) This careful supervision helped maintain consistency in patient outcomes and provided expert guidance throughout the rehabilitation period.

2.5. Functional Assessment

The functional outcomes of foot and ankle surgeries in group 1 were evaluated using the AOFAS (American Orthopedic Foot and Ankle Society) scale. Baseline assessments using the AOFAS scale were performed preoperatively to establish the initial functional status of patients in group 1. These assessments were conducted by trained healthcare professionals experienced in using the AOFAS scale to ensure consistency and accuracy of the measurements. Postoperative assessments using the AOFAS scale were conducted at specified time points including 3 months, 6 months, 12 months, and 24 months after the surgery, to track the functional improvement in group 1 patients. The follow-up assessments aimed to determine the long-term outcomes and evaluate the effectiveness of the surgical intervention.

2.6. Statistical Analysis

Data analysis was conducted using Excel 16.0 and SPSS v24 software. The significance level was set at p < 0.05 to determine statistical significance. The analysis included all participants in the study including those who experienced complications during the postoperative period such as autograft tear, ankle joint instability in the main group, or sural nerve injury in the main group. For variables that followed a normal distribution with 95% confidence, such as the Lysholm Knee Questionnaire scores, parametric statistical tests were employed. These included independent t-tests or analysis of variance (ANOVA) with post hoc tests for between-group comparisons. For variables that did not follow a normal distribution, non-parametric statistical tests were used. The Mann–Whitney U test was utilized to examine the differences between groups.
Appropriate measures of central tendency (mean or median) and dispersion (standard deviation or interquartile range) were reported for continuous variables, while frequencies and percentages were used for categorical variables. Effect sizes were calculated where applicable to assess the magnitude of differences between groups. Confidence intervals were determined to provide estimates of the precision of the study findings. Additionally, appropriate adjustments for multiple comparisons were applied when necessary. All statistical analyses were conducted by a trained statistician following the established guidelines and recommendations for analyzing clinical data.

2.7. Rehabilitation

Patients were discharged 5 days post-surgery after two dressing checks. Both groups were treated with the same standard physiotherapy protocol. In the first 2 weeks, knee flexion was started up to 90° along with quadricep and hamstring strengthening exercises, ankle pump exercises, active straight leg raising with a knee brace with complete extension and toe touch weight-bearing with a knee brace in extension supported by a walker. In the following 6–12 weeks, exercises included full range of knee flexion, stationary cycling, and weight-bearing as tolerated. The walker was weaned off depending on the strength of the quadriceps. Ankle eversion strengthening exercises were advised to patients belonging to the peroneus longus group. By 6–12 weeks, the knee brace was discontinued, and partial squatting was started. After 6 months, patients could return to sporting activity. Knee band support was advised for contact sports during jumping and landing activities for 1 year.

3. Results

In our study, 110 patients with an ACL injury were operated. Table 2, Table 3 and Table 4 show all of the details.
Group H had significantly better knee function both preoperatively and 24 months postoperatively compared to Group P. These findings suggest a consistent and significant advantage in knee function for patients in Group H throughout the study period (Figure 3).
Table 4 demonstrates that patients who received six-strand hamstring tendon autografts (Group H) had significantly better functional outcomes, as measured by the IKDC score, both preoperatively and at 3, 6, 12, and 24 months postoperatively, compared to those who received peroneus longus tendon autografts (Group P). This suggests that the hamstring tendon autografts provide superior knee function and recovery over time (Figure 4; Table 5 and Table 6).
The pivot shift test results indicate that both the six-strand hamstring tendon autograft (Group H) and the peroneus longus tendon autograft (Group P) are effective in improving knee stability post-ACL reconstruction. Over the 2-year follow-up period, both groups showed a substantial increase in the number of patients achieving normal stability (Grade 0), with Group P having a slightly higher number of patients with normal stability at the final follow-up. These findings suggest that both graft types are effective, with the peroneus longus tendon showing a marginally better outcome in terms of achieving normal knee stability (Table 7, Table 8 and Table 9).

4. Discussion

This study aimed to compare the functional outcomes of ACL reconstruction using the six-strand hamstring tendon (Group H) and the peroneus longus tendon (Group P). By evaluating the mean Lysholm and IKDC scores preoperatively and at 24 months postoperatively, our results indicate that Group H consistently exhibited significantly better knee function both preoperatively and postoperatively at 24 months. The demographic and baseline characteristics between the two groups (Group H and Group P) were relatively comparable, ensuring that any differences observed in postoperative outcomes could be attributed more confidently to the type of graft used rather than to differences in the patient demographics. Both groups had a higher number of male patients and right-side involvements. The mean age, height, weight, and graft diameters were similar between the two groups, providing a solid basis for a comparative analysis of the functional outcomes and complications associated with each graft type (Table 1).
Our findings align with previous studies indicating the efficacy of hamstring tendon autografts in ACL reconstruction. The higher preoperative and postoperative Lysholm and IKDC (table) scores in Group H suggest superior baseline function and better recovery outcomes compared to Group P. This corroborates research by Kumar et al., who found that hamstring tendon autografts were associated with minimal donor site morbidity and good functional outcomes, particularly in the Asian population where this technique is prevalent [17].
However, the use of the peroneus longus tendon as an autograft, while less common, has been explored for its potential benefits. Rhatomy et al. [18] highlighted that the peroneus longus tendon could be a superior graft choice for ACL reconstruction, citing its comparable tensile strength to the hamstring tendon and the added advantage of avoiding hamstring muscle strength reduction, which is crucial for athletic performance.

4.1. Clinical Outcomes and Functional Assessments

Our study indicates that patients in Group H demonstrated superior knee function both preoperatively and maintained this advantage postoperatively, with a significant improvement in Lysholm score compared to Group P (Table 2). The mean Lysholm score for Group H at 24 months was 92.80 ± 2.91, whereas for Group P, it was 89.20 ± 2.40. This consistent superiority suggests that the hamstring tendon graft may provide better long-term knee stability and function.
The Lysholm Knee Scoring Scale, widely used to evaluate knee function and symptoms, encompasses several dimensions including pain, instability, locking, swelling, and the ability to perform daily activities. The higher scores in Group H across all postoperative intervals indicate not only superior joint stability, but also reduced symptomatology and improved functional capacity.
These findings are consistent with the work of Rudy et al. [19], who conducted a similar comparative study and reported higher Lysholm scores in patients receiving hamstring tendon grafts compared to those with patellar tendon grafts. The superior outcomes to the biomechanical properties of the hamstring graft, which closely mimic the native ACL, thereby provide better functional integration and joint kinematics post-reconstruction. Their study, which included a follow-up period of 24 months, aligns with our results, reinforcing the conclusion that hamstring tendon grafts are advantageous for ACL reconstruction in terms of knee function and stability [19].
Moreover, our findings are supported by the research by Laoruengthana et al. [20], who reported that patients with hamstring grafts exhibited fewer instances of graft failure and re-injury compared to those with patellar tendon grafts. This reduced failure rate can be attributed to the hamstring graft’s superior tensile strength and flexibility, which better accommodate the dynamic stresses placed on the knee joint during high-impact activities and sports. A meta-analysis by Migliorini et al. [21] further substantiates our results, showing that hamstring grafts are associated with higher patient satisfaction, lower complication rates compared to other graft types, and returning to work. The meta-analysis included over 95,575 procedures that were retrieved and concluded that hamstring tendon autografts resulted in better Lysholm scores, reduced anterior knee pain, and lower rates of postoperative stiffness and graft site morbidity [21].
The International Knee Documentation Committee (IKDC) scores further support the functional superiority of Group H. Both groups showed significant improvement over time, but Group H had consistently higher IKDC scores at all postoperative intervals. At the 24-month mark, Group H had an IKDC score of 94.43 ± 1.59, compared to 90.84 ± 2.44 for Group P, highlighting a significant difference favoring the hamstring tendon graft (Figure 3, Table 3).
These results are consistent with the findings of Urchek et al. [22], who demonstrated that patients with hamstring grafts achieved significantly better IKDC scores post-ACL reconstruction compared to those with patellar tendon grafts. Grassi et al. [23] attributed this difference to the biomechanical and histological properties of hamstring grafts, which provide better mimicry of the native ACL, leading to superior functional integration and joint stability. In addition, a systematic review and meta-analysis by DeFazio et al. [24] corroborates our findings, indicating that hamstring autografts result in better IKDC scores and overall knee function compared to bone-patellar tendon-bone autografts. Their analysis, encompassing multiple studies with large patient cohorts, emphasized the reduced donor site morbidity and improved patient-reported outcomes associated with hamstring grafts.

4.2. Anterior Drawer Test and Lachman’s Test

The anterior drawer and Lachman’s tests, which are critical for assessing anterior knee stability, also indicated better outcomes for Group H. At the two-year follow-up, a higher proportion of patients in Group H achieved Grade 0 (normal stability) compared to Group P, as detailed in Table 4 and Table 5. Specifically, 15 out of 55 patients in Group H had Grade 0 on the anterior drawer test, while only 12 out of 55 in Group P reached this level of stability. Similarly, the Lachman’s test results showed that 14 patients in Group H achieved Grade 0 compared to 12 in Group P at the same follow-up point.
These findings align with the research conducted by DeFazio et al. [24] (2020), who reported superior stability outcomes with hamstring grafts compared to patellar tendon grafts. DeFazio et al.’s study included 20 articles investigating a total of 2348 athletes and highlighted that hamstring grafts tended to exhibit better biomechanical properties, such as higher tensile strength and elasticity, which are crucial for maintaining knee stability post-surgery. Their long-term follow-up data suggested that hamstring grafts are less prone to stretching and laxity, which contributes to the higher stability scores observed in clinical assessments, and the autograft had an overall return to sport (RTS) rate of 70.6%, with 48.5% of athletes returning to preinjury levels of performance and a re-rupture rate of 2.5%.
Lin et al. [25] found that patients with hamstring tendon grafts had significantly lower rates of graft failure and re-rupture compared to those with other graft types. Lin et al. [25] concluded that the structural composition of hamstring tendons, which includes a higher collagen content and more favorable alignment of collagen fibers, contributes to their superior performance in reconstructive surgery [26].

4.3. Surgical and Rehabilitation Protocols

The standardized surgical and rehabilitation protocols applied to both groups ensured that the observed differences in outcomes could be attributed to the graft type rather than variations in surgical technique or postoperative care. Both groups underwent identical surgical procedures performed by experienced surgeons, minimizing the risk of procedural discrepancies affecting the results.
Postoperative rehabilitation was also standardized, emphasizing the early initiation of weight-bearing and knee mobility exercises. This approach is critical in promoting optimal recovery by enhancing muscle strength, joint flexibility, and overall functionality. Both groups began with quadricep and hamstring strengthening exercises, ankle pump exercises, and active straight leg raising within the first two weeks post-surgery. This regimen helped in preventing postoperative complications such as joint stiffness and muscle atrophy [27]. From weeks three to six, patients were encouraged to achieve a full range of knee flexion and engage in stationary cycling and weight-bearing activities as tolerated. By six to twelve weeks, the knee brace was discontinued, and partial squatting exercises were introduced. By the sixth month, patients were allowed to return to sports activities, with knee band support recommended for high-impact activities [28]. This structured and early rehabilitation protocol contributed to the positive recovery trajectories observed in both groups, as supported by research from Mohan et al. (2023), who demonstrated that early mobilization significantly improved postoperative outcomes in ACL reconstruction patients [29].

4.4. Complications and Donor Site Morbidity

While both graft types are associated with specific complications, the peroneus longus tendon graft presented unique challenges. Group P experienced higher incidences of donor site morbidity including ankle instability and sural nerve injury, although these were not statistically significant (Table 7). This finding concurs with previous studies by Hardy et al. (2023), who highlighted the potential for ankle instability following peroneus longus tendon harvesting. The peroneus longus tendon plays a critical role in ankle stability and eversion, and its removal can compromise these functions, leading to the observed complications [30,31]. On the other hand, hamstring grafts were associated with muscle weakness, particularly in the hamstrings, which is a critical consideration for athletes who rely heavily on hamstring strength for performance. This muscle weakness can affect activities that require strong hamstring contractions such as sprinting and jumping. However, studies by Dietvorst et al. [32] showed that with targeted rehabilitation, hamstring strength can be effectively restored, minimizing long-term deficits [33].
The overall complication rates between the two groups were comparable, with minor variations in the type and incidence of complications. For instance, Group H had instances of cyclops syndrome and permanent hemarthrosis, whereas Group P had cases of knee stiffness and instability. These differences underscore the importance of individualized patient assessment and tailored rehabilitation protocols to address specific risks associated with each graft type [29].
Despite these complications, the superior functional outcomes and stability achieved with the hamstring graft, as indicated by the Lysholm and IKDC scores, suggest that the benefits of this graft type outweigh the associated risks. This is supported by the work of Tutkus et al. [34], who found that hamstring grafts provided excellent functional results with minimal long-term complications when appropriate rehabilitation protocols were followed [35].
The smaller effect sizes for the anterior drawer test (Cohen’s d = 0.25) and Lachman’s test (Cohen’s d = 0.20) suggest that the hamstring graft offers a slight but notable advantage in anterior knee stability. However, the minimal effect size observed in the pivot shift test (Cohen’s d = −0.10) indicates that both grafts are comparable in terms of rotational stability, with only a slight, clinically insignificant preference for the peroneus longus tendon (Table 9).

4.5. Biomechanical Efficacy

The peroneus longus tendon has shown biomechanical properties that are comparable to the hamstring tendon. Both tendons exhibit similar tensile strength, which is crucial for withstanding the forces exerted on the knee joint post-surgery. A biomechanical study demonstrated that the PLT could handle loads and stresses comparable to those managed by the HT, making it a robust alternative for ACL reconstruction [19]. The biomechanical superiority of hamstring autografts, as demonstrated, efficacy for ACL reconstruction. Enhanced knee stability, increased graft diameter, and superior rotational stability are key attributes that define the biomechanical advantage of 6HS autografts over traditional four-strand grafts. For example, the work by Laoruengthana et al. [21] and Nazari et al. [22] showed that hamstring autografts consistently achieved a graft diameter of 8 mm or greater, a dimension correlated with reduced graft failure and re-injury rate. This larger diameter mimics the native ACL more closely, providing better resistance to the forces exerted on the knee during physical activities.
Zhang et al. [36] has shown that hamstring autografts exhibit superior biomechanical properties in terms of load-bearing capacity and stiffness, which are crucial for the long-term success of ACL reconstruction and the prevention of osteoarthritis development in the knee joint. For instance, biomechanical testing has shown that hamstring autografts can withstand higher peak loads before failure compared to traditional four-strand grafts, which translates to a lower risk of graft rupture during high-impact activities. Furthermore, the integration of the hamstring autograft with the bone is a critical factor in the long-term success of the reconstruction [37,38]. The larger surface area of the graft promotes better osseointegration and faster biological healing, facilitating a more robust anchorage within the bone tunnels [31]. This not only accelerates the rehabilitation process but also minimizes the potential for graft slippage or pull-out, which are common complications associated with smaller grafts.
While hamstring autografts demonstrate robust outcomes, graft failure remains a potential risk, influenced by several factors. The size and handling of the graft are crucial; larger grafts, like those used in hamstring reconstructions, are typically associated with lower failure rates due to their strength and biomechanical compatibility with the knee’s natural movements. Surgical technique is another vital factor. The precision in tunnel placement and the efficacy of graft fixation plays fundamental roles in the initial stability and long-term integration of the graft. Incorrect tunnel placement or suboptimal fixation can lead to abnormal mechanics and increased graft strain, potentially leading to failure [39].
Several studies have compared various graft options for ACL reconstruction, each highlighting different advantages and limitations. For instance, Zhao et al. [40] emphasized the superior bone-to-bone healing properties of the bone-patellar tendon-bone (BPTB) graft, which accelerates recovery and is favored by athletes due to its robust initial fixation and high tensile strength. The bone-to-bone healing process typically allows for quicker graft integration within the bone tunnels, potentially leading to faster rehabilitation and return to sports activities [40].
However, BPTB grafts are also associated with significant complications such as patellar fractures, anterior knee pain, and patellar tendinitis, which are less prevalent with hamstring and peroneus longus grafts. These complications can impede the recovery process and affect long-term knee function, particularly in activities involving kneeling and squatting, which are common in various sports and daily activities [41].
In contrast, studies like those by Vari et al. [42] highlighted the advantages of hamstring tendon grafts including lower donor site morbidity, reduced incidence of anterior knee pain, and preservation of the extensor mechanism. These benefits make hamstring grafts particularly suitable for younger athletes and those engaged in sports that require extensive knee flexion. The hamstring graft’s flexibility and strength also contribute to its favorable outcomes in terms of stability and functionality, as supported by our study’s superior IKDC and Lysholm scores for Group H [42,43]. Similarly, our study aligns with the findings of Mascarenhas and Lima [44], who noted that hamstring autografts lead to better patient-reported outcomes and lower rates of postoperative complications compared to BPTB grafts. These studies collectively reinforce the conclusion that while BPTB grafts may offer some biomechanical advantages, the hamstring tendon graft provides a better overall balance of functional recovery and complication risk [45,46,47,48].
As demonstrated in Table 10, the choice of graft in ACL reconstruction plays a crucial role in determining the functional outcomes and potential complications. Each graft type offers unique advantages and disadvantages that must be carefully considered when planning surgery. For instance, while the six-strand hamstring tendon graft (Group H) provides strong knee stability and is well-suited for athletes, it carries the risk of hamstring strength reduction [1,17,30,49].
On the other hand, the peroneus longus tendon graft (Group P) offers the benefit of preserving hamstring strength but may lead to higher donor site morbidity including ankle instability and sural nerve injury [5,7,35,50].
The bone-patellar tendon-bone (BPTB) graft remains a popular choice due to its strong bone-to-bone healing properties and high initial stability, making it ideal for contact sports [1,25,30]. However, it is associated with significant donor site complications such as anterior knee pain and patellar fractures. The quadriceps tendon graft offers a robust alternative with a lower risk of anterior knee pain but may result in quadricep muscle weakness [22,39,51]. Allografts, while eliminating donor site morbidity, pose a higher risk of graft rejection and slower integration, making them less ideal for younger, more active patients [23,29,52]. The decision to use a specific graft should be individualized by considering the patient’s activity level, previous injuries, and specific surgical goals.
Table 10. Comparative table of ACL grafts.
Table 10. Comparative table of ACL grafts.
Graft TypeAdvantagesDisadvantages
Six-strand hamstring tendon
[1,17,29,47]
  • Strong, resilient, excellent stability
  • Lower donor site morbidity
  • Suitable for athletes
  • Potential hamstring strength reduction
  • Graft size variability
  • Longer graft integration time
Peroneus longus tendon
[5,7,34,48]
  • Comparable strength to hamstring
  • Preserves hamstring strength
  • Alternative for hamstring issues
  • Higher donor site morbidity
  • Risk of sural nerve injury
  • Limited long-term studies
Bone-patellar tendon-bone (BPTB)
[1,24,29]
  • Strong bone-to-bone healing
  • High initial stability
  • Considered gold standard
  • Anterior knee pain, patellar tendinitis
  • Risk of patellar fractures
  • Larger surgical incision
Quadriceps tendon
[22,38,49]
  • Thick, robust graft
  • Lower risk of anterior knee pain
  • Suitable for those with previous injuries
  • Potential quadriceps weakness
  • Limited long-term data
  • Complex harvesting technique
Allografts (donor tissue)
[23,28,52]
  • No donor site morbidity
  • Quicker recovery time
  • Suitable for older, less active patients
  • Risk of graft rejection
  • Slower graft integration
  • Lower tensile strength, higher re-rupture risk

4.6. Future Directions

Future research should continue to explore the long-term outcomes of ACL reconstruction with different autografts including the peroneus longus tendon. Larger, multicentric studies with extended follow-up periods could provide more comprehensive data on the durability of these grafts and their impact on knee function over time. Additionally, biomechanical studies comparing the graft integration and healing processes of different tendons could further elucidate the reasons behind the observed differences in functional outcomes.
The landscape of ACL reconstruction and rehabilitation is rapidly evolving with advancements in regenerative medicine, offering promising new treatment avenues that could potentially enhance the outcomes and speed of recovery for patients. Regenerative medicine focuses on the repair and regeneration of damaged tissues using biological therapies, and one such innovative approach is the use of stromal vascular fraction (SVF) [53,54,55,56,57,58]. Mesenchymal stem cells (MSCs): MSCs are multipotent cells capable of differentiating into various cell types including osteoblasts, chondrocytes, and tenocytes. These cells can be harvested from bone marrow, adipose tissue, or umbilical cord blood and have been shown to promote tissue regeneration and repair by secreting bioactive molecules that modulate the local environment of the injury site. MSCs can be injected directly into the ACL graft or surrounding tissues during surgery. This can enhance the integration of the graft with the native bone and ligament tissue, accelerating the healing process and improving the overall strength and stability of the knee joint [59,60,61,62].
Platelet-rich plasma (PRP): PRP is derived from the patient’s own blood and contains a high concentration of platelets, growth factors, and cytokines that play a crucial role in wound healing and tissue regeneration. PRP can be applied to the graft site during ACL surgery to stimulate cellular proliferation, collagen production, and angiogenesis. This can enhance the healing of the graft, reduce inflammation, and decrease the recovery time [63,64,65].

4.7. Limitations of the Study

Despite the significant findings and contributions of this study, several limitations should be acknowledged.
Sample size and single-center design: The study included a relatively small sample size of 110 patients, which may limit the generalizability of the results. A larger, multicentric study would provide more robust data and improve the external validity of the findings.
Short follow-up period: The follow-up period of 24 months, while sufficient to assess short- to medium-term outcomes, may not capture long-term complications and the durability of the surgical interventions. Longer follow-up periods are necessary to evaluate the sustainability of the functional improvements and the incidence of late-onset complications.
Surgeon experience and technique standardization: The surgeries were performed by three experienced surgeons with similar techniques; however, slight variations in surgical skill and technique could influence the outcomes. Standardizing surgical techniques and ensuring uniformity across different surgeons and centers would mitigate this limitation.
Lack of blinding: The study did not mention whether blinding was implemented for patients, surgeons, or evaluators. Blinding is crucial to reduce performance and detection bias. Future studies should consider blinding to enhance the objectivity of the outcomes.
Limited postoperative rehabilitation data: The study provided a standardized postoperative care protocol, but individual adherence to rehabilitation protocols and variations in physical therapy could impact the recovery outcomes. Detailed documentation and the analysis of rehabilitation adherence and its effects on outcomes would provide valuable insights.
Exclusion of certain patient populations: The exclusion criteria eliminated patients with systemic diseases, osteoarthritic knees, and other significant injuries. While necessary for study control, this exclusion limits the applicability of the results to a broader, more diverse patient population commonly encountered in clinical practice.
Focus on specific graft types: The study compared only two types of autografts (hamstring tendon and peroneus longus tendon). Including other commonly used grafts, such as the bone-patellar tendon-bone (BPTB) graft, would provide a more comprehensive comparison of graft options for ACL reconstruction.
Subjective assessment measures: While the Lysholm and IKDC scores are widely used and validated, they are subjective measures that rely on patient self-reporting. Incorporating more objective measures of knee function, such as biomechanical assessments or imaging studies, could complement the subjective scores and provide a more holistic evaluation of knee function.
Potential confounding factors: The study did not account for potential confounding factors such as the patients’ activity level, occupation, or comorbidities, which could influence the outcomes. Future research should include these variables to better understand their impact on ACL reconstruction results.

5. Conclusions

This comparative study highlighted the superior efficacy of the six-strand hamstring tendon (Group H) over the peroneus longus tendon (Group P) for ACL reconstruction. Patients in Group H exhibited significantly better functional outcomes, evidenced by higher Lysholm and IKDC scores and greater knee stability, both preoperatively and at 24 months postoperatively.
The hamstring tendon’s biomechanical properties, closely mimicking the native ACL, contributed to enhanced recovery and reduced complications. Conversely, the peroneus longus tendon, while showing comparable tensile strength, was associated with higher donor site morbidity including ankle instability and sural nerve injury. Standardized surgical techniques and postoperative care protocols validated the observed differences in functional outcomes.
Our findings align with the existing literature on the advantages of hamstring tendon autografts in ACL reconstruction, emphasizing their minimal donor site morbidity and superior functional outcomes. Future research should focus on larger, multicentric studies with extended follow-up periods to provide comprehensive data on graft durability and long-term knee function. Additionally, the integration of regenerative medicine techniques, such as mesenchymal stem cells and platelet-rich plasma, holds promise for enhancing ACL reconstruction success.

Author Contributions

Conceptualization, O.A.V., N.A.V. and N.M.; Methodology, O.A.V., D.B. and K.K.I.; Validation, O.A.V., N.A.V., D.B., K.K.I., E.G., O.K., E.B., M.D.J.E.R. and N.M.; Formal analysis, K.K.I., E.G., O.K., E.B. and N.M.; Investigation, K.K.I., E.G., O.K., E.B. and M.D.J.E.R.; Data curation, O.A.V., N.A.V., M.D.J.E.R. and N.M.; Writing—original draft preparation, O.A.V., N.A.V., D.B., K.K.I. and E.G.; Writing—review and editing, E.B., M.D.J.E.R. and N.M.; Visualization, O.A.V., M.D.J.E.R. and N.M.; Supervision, M.D.J.E.R. and N.M. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the local Academician B. V. Petrovsky, Moscow, Russia (11/2022).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data presented in this study are available on request from the corresponding author due to privacy.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. (A) Harvesting a PLT autograft from the patient’s left leg. (B) A ready-for-use PLT graft.
Figure 1. (A) Harvesting a PLT autograft from the patient’s left leg. (B) A ready-for-use PLT graft.
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Figure 2. (A) Equal length by loops at the end of a 6-strand hamstring tendon graft. (B) A 6-strand hamstring anterior cruciate ligament (ACL) graft is prepared by tripling both the semitendinosus and gracilis tendons.
Figure 2. (A) Equal length by loops at the end of a 6-strand hamstring tendon graft. (B) A 6-strand hamstring anterior cruciate ligament (ACL) graft is prepared by tripling both the semitendinosus and gracilis tendons.
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Figure 3. Patients who received six-strand hamstring tendon autografts (Group H) had significantly better functional outcomes as measured by the Lysholm Score, both preoperatively and at 3, 6, 12, and 24 months postoperatively, compared to those who received peroneus longus tendon autografts (Group P). This suggests that the hamstring tendon autografts provide superior knee function and recovery over time.
Figure 3. Patients who received six-strand hamstring tendon autografts (Group H) had significantly better functional outcomes as measured by the Lysholm Score, both preoperatively and at 3, 6, 12, and 24 months postoperatively, compared to those who received peroneus longus tendon autografts (Group P). This suggests that the hamstring tendon autografts provide superior knee function and recovery over time.
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Figure 4. The mean IKDC scores were comparable between the two groups at each follow-up. In both groups, the mean IKDC score showed an improvement over the period of follow-up; Group H showed significantly better knee function compared to Group P. These findings suggest a significant and effective improvement in knee function for patients in Group H post-treatment. Unpaired ‘t’ test applied. p value < 0.05 was taken as statistically significant.
Figure 4. The mean IKDC scores were comparable between the two groups at each follow-up. In both groups, the mean IKDC score showed an improvement over the period of follow-up; Group H showed significantly better knee function compared to Group P. These findings suggest a significant and effective improvement in knee function for patients in Group H post-treatment. Unpaired ‘t’ test applied. p value < 0.05 was taken as statistically significant.
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Table 1. Follow-up assessment methods after ACL reconstruction.
Table 1. Follow-up assessment methods after ACL reconstruction.
Time Point
Post-Surgery		Clinical
Examination		Functional
Assessment
3 monthsLachman test, wound inspection, anterior drawerIKDC-2000, Lysholm score, range of motion
6 monthsLachman test, wound inspection, pivot-shift test, anterior drawer testIKDC-2000, Lysholm score
12 monthsLachman test, pivot-shift test, anterior drawer testIKDC-2000, Lysholm score
24 monthsLachman test, pivot-shift test, anterior drawer testIKDC-2000, Lysholm score
Table 2. Summary of patient data.
Table 2. Summary of patient data.
Group H
(Hamstring Tendon)		Group P
(P. Longus Tendon)
Total patients5555
Sex
Male4138
Female1417
Side involved
Left side13 (23.64%)8 (14.55%)
Right side42 (76.36%)47 (85.45%)
Mean age (years)33.10 ± 4.1732.90 ± 6.98
Mean height178.00 ± 5.05 cm180.95 ± 4.53 cm
Mean weight83.40 ± 2.56 kg87.25 ± 3.34 kg
Average graft diameter8.3 ± 0.47 mm8.4 ± 0.35 mm
Table 3. Comparison of the mean Lysholm score between the two groups.
Table 3. Comparison of the mean Lysholm score between the two groups.
Time PeriodGroup H
(Mean ± SD)		Group P
(Mean ± SD)
Preoperative32.50 ± 4.3529.00 ± 2.05
At 3 months71.00 ± 2.6065.00 ± 3.40
At 6 months82.80 ± 3.4578.60 ± 3.45
At 12 months90.26 ± 1.3088.80 ± 1.00
At 24 months92.80 ± 2.9189.20 ± 2.40
Unpaired ‘t’ test applied. p value < 0.05 was taken as statistically significant.
Table 4. Comparison of the mean IKDC score between the two groups.
Table 4. Comparison of the mean IKDC score between the two groups.
Time PeriodGroup H
(Mean ± SD)		Group P
(Mean ± SD)		‘t’ Value, dfp Value
Preoperative36.27 ± 2.3138.77 ± 1.84−6.26 = 108<0.0001
At 3 months68.70 ± 3.5570.00 ± 2.80−2.19, df = 1080.031
At 6 months77.48 ± 5.2475.77 ± 1.302.40, df = 1080.018
At 12 months92.00 ± 2.0090.84 ± 1.303.50, df = 1080.001
At 24 months94.43 ± 1.5990.84 ± 2.449.14 = 108<0.0001
Table 5. Anterior drawer test analysis in the HTS and PL groups pre- and postoperative follow-up after 3 months, 6 months, 1 year, and 2 years.
Table 5. Anterior drawer test analysis in the HTS and PL groups pre- and postoperative follow-up after 3 months, 6 months, 1 year, and 2 years.
Time PointGradeHamstring (Group H) Pre-OperativeHamstring (Group H) 3 Months Follow-UpHamstring (Group H) 6 Months Follow-UpHamstring (Group H) 1 Year Follow-UpHamstring (Group H) 2 Years Follow-UpPeroneus Longus (Group P) Pre-OperativePeroneus Longus (Group P) 3 Months Follow-UpPeroneus Longus (Group P) 6 Months Follow-UpPeroneus Longus (Group P) 1 Year Follow-UpPeroneus Longus (Group P) 2 Years Follow-Up
Anterior drawer test (ADT)Grade 0 (1–2 mm)0610141507121718
Grade I (3–5 mm)0857608665
Grade II (6–10 mm)12106111210700
Grade III (>10 mm)101000112000
Table 6. Lachman’s test analysis in the HTS and PL groups pre- and postoperative follow-up after 3 months, 6 months, 1 year, and 2 years follow-up.
Table 6. Lachman’s test analysis in the HTS and PL groups pre- and postoperative follow-up after 3 months, 6 months, 1 year, and 2 years follow-up.
Time PointGradeHamstring (Group H) Pre-OperativeHamstring (Group H) 3 Months Follow-UpHamstring (Group H) 6 Months Follow-UpHamstring (Group H) 1 Year Follow-UpHamstring (Group H) 2 Years Follow-UpPeroneus Longus (Group P) Pre-OperativePeroneus Longus (Group P) 3 Months Follow-UpPeroneus Longus (Group P) 6 Months Follow-UpPeroneus Longus (Group P) 1 Year Follow-UpPeroneus Longus (Group P) 2 Years Follow-Up
Lachman’s test (LT)Grade 0 (1–2 mm)0510131406151819
Grade I (3–5 mm)0658706754
Grade II (6–10 mm)1410411108400
Grade III (>10 mm)84000136000
Table 7. Pivot shift test analysis in the HT and PL groups.
Table 7. Pivot shift test analysis in the HT and PL groups.
Time PointGradeHamstrings Pre-OperativeHamstrings 6 Months Follow-UpHamstrings 1 Year Follow-UpHamstrings 2 Years Follow-UpPeroneus Longus Pre-OperativePeroneus Longus 6 Months Follow-UpPeroneus Longus 1 Year Follow-UpPeroneus Longus 2 Years Follow-Up
Pivot shift test (PST)Equal51216186141820
Glide I79644653
Clunk II63008300
Gross III30006000
Table 8. Comparison of postoperative complications between the two groups.
Table 8. Comparison of postoperative complications between the two groups.
Postoperative ComplicationsGroup HGroup P
Knee stiffness02
Infection requiring arthroscopic debridement00
Case of cyclops syndrome11
Case of permanent hemarthrosis10
Case of permanent synovitis10
Case of severe contracture of knee joint11
Case of instability12
Table 9. Comparative analysis of functional outcomes between Group H and Group P.
Table 9. Comparative analysis of functional outcomes between Group H and Group P.
Outcome MeasureGroup H
(Six-Strand Hamstring)		Group P
(Peroneus Longus)		Effect Size
(Cohen’s d)
Lysholm score92.80 ± 2.9189.20 ± 2.400.55
IKDC score94.43 ± 1.5990.84 ± 2.440.65
Anterior drawer test (Grade 0)15120.25
Lachman’s test (Grade 0)14120.20
Pivot shift test (Grade 0)1820−0.10
Complications (Total)56N/A
Note: The six-strand hamstring tendon (Group H) generally provided better knee function and stability than the peroneus longus tendon (Group P), as indicated by moderate effect sizes (Cohen’s d = 0.55 for Lysholm and 0.65 for IKDC). Group H showed superior performance in functional outcomes, particularly in knee stability, while the difference in rotational stability was minimal. Both groups had comparable complication rates, with slightly different types of complications reported.
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MDPI and ACS Style

Vyacheslavovich, O.A.; Vladimirovna, N.A.; Bekzhan, D.; Ivanovich, K.K.; Goncharov, E.; Koval, O.; Bezuglov, E.; Ramirez, M.D.J.E.; Montemurro, N. Comparative Analysis of the Six-Strand Hamstring and Peroneus Longus in Sports Medicine and Rehabilitation. Surgeries 2024, 5, 778-798. https://doi.org/10.3390/surgeries5030063

AMA Style

Vyacheslavovich OA, Vladimirovna NA, Bekzhan D, Ivanovich KK, Goncharov E, Koval O, Bezuglov E, Ramirez MDJE, Montemurro N. Comparative Analysis of the Six-Strand Hamstring and Peroneus Longus in Sports Medicine and Rehabilitation. Surgeries. 2024; 5(3):778-798. https://doi.org/10.3390/surgeries5030063

Chicago/Turabian Style

Vyacheslavovich, Ondar Artysh, Nikonova Alina Vladimirovna, Dzhunusov Bekzhan, Khaizhok Konstantin Ivanovich, Evgeniy Goncharov, Oleg Koval, Eduard Bezuglov, Manuel De Jesus Encarnacion Ramirez, and Nicola Montemurro. 2024. "Comparative Analysis of the Six-Strand Hamstring and Peroneus Longus in Sports Medicine and Rehabilitation" Surgeries 5, no. 3: 778-798. https://doi.org/10.3390/surgeries5030063

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