<![CDATA[Background: Graft selection is a key determinant of outcomes after anterior cruciate ligament reconstruction (ACLR). The anterior half peroneus longus tendon (PL) has emerged as an alternative autograft that may preserve hamstring–quadriceps balance while providing adequate graft size and strength, but its role relative to established grafts remains unclear. Methods: A narrative review of biomechanical studies, randomized controlled trials, cohort studies, and systematic reviews was conducted to compare ACLR using PL, hamstring tendon (HT), quadriceps tendon (QT), and bone–patellar tendon–bone (BPTB) autografts. Outcomes included graft mechanical properties, muscle strength balance, knee stability, clinical scores, donor-site morbidity, rehabilitation considerations, and harvesting techniques. Results: The anterior half PL autograft provides sufficient tensile strength and consistent graft diameter (≥8 mm), with knee stability and functional outcomes comparable to HT grafts. PL grafts demonstrate advantages in harvest time, graft size, and donor-site morbidity, while preserving hamstring strength and hamstring–quadriceps balance. Ankle function is largely maintained with appropriate tenodesis. QT grafts show greater early quadriceps weakness, and BPTB grafts are associated with higher anterior knee pain. Conclusion: The anterior half peroneus longus autograft is a viable alternative for ACL reconstruction.]]>
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