Graft diameter, not graft type, predicts outcomes in single-stage revision ACL reconstruction: A comparison of peroneus longus and contralateral hamstring autografts

Purpose: To compare clinical outcomes, postoperative stability, graft rerupture and return to sport (RTS) outcomes between ipsilateral peroneus longus tendon (PLT) and contralateral hamstring tendon (HT) autografts in isolated single-stage revision anterior cruciate ligament reconstruction (ACLR), and to evaluate the association between graft diameter and postoperative outcomes. Methods: This retrospective cohort study included 44 patients who underwent isolated single-stage revision ACLR between 2017 and 2023 (PLT: 23; HT: 21), with a minimum follow-up of 24 months. Additional ligament procedures and lateral extra-articular procedures were excluded. Graft choice was determined intraoperatively based on tunnel quality and graft availability following preoperative shared decision-making. Functional outcomes (Lysholm, International Knee Documentation Committee [IKDC], Tegner), knee stability (Lachman and pivot-shift), American Orthopaedic Foot and Ankle Society (AOFAS) scores, complications and RTS outcomes were assessed. RTS was defined as achieving a postoperative Tegner score equal to or greater than the preinjury level. Logistic regression explored associations between graft diameter and postoperative instability, graft rerupture and RTS achieved. Receiver operating characteristic (ROC) analysis evaluated the discriminative ability of graft diameter for RTS. Results: Mean age was 30.8 ± 6.8 years in the HT group and 31.0 ± 7.2 years in the PLT group, with comparable sex distribution between groups. Mean follow-up was 43.6 ± 9.3 months. Graft diameter was larger in the PLT group (8.8 ± 0.7 vs. 8.0 ± 0.6 mm; p < 0.001), while functional outcomes, postoperative stability and RTS rates were similar between groups (all p > 0.35). Overall RTS rate was 33/44 (75.0%). Greater graft diameter was associated with lower odds of postoperative instability and graft rerupture, and higher likelihood of RTS achieved. ROC analysis identified a graft diameter threshold of ≥8.25 mm for RTS prediction (area under the receiver operating characteristic curve [AUC] = 0.796). Conclusion: In isolated revision ACLR, graft diameter was associated with postoperative stability, graft survival and RTS outcomes, independent of graft type. Level of Evidence: Level III, retrospective comparative study.