Quadriceps Tendon Anterior Cruciate Ligament Reconstruction: A Systematic Review of Postoperative Rehabilitation and Complication Profiles

Zhang, Kailai; Beshay, Tony; Murphy, Ben; Sheean, Andrew J.; de, Darren

doi:10.1016/j.arthro.2021.12.020

Cited by 10 publications

(5 citation statements)

References 85 publications

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“…Currently, we have similar approaches to rehabilitation after ACLR, irrespective of graft choice. 34 However, the findings of our study and other studies with similar results 13,26,28 indicate that rehabilitation approaches may need to be tailored to graft choice. A tailored rehabilitation approach for QT grafts may facilitate the recovery of quadriceps strength in these patients and narrow the gap between them and patients with other grafts.…”

Section: Implications For Rehabilitation and Future Researchsupporting

confidence: 71%

Weaker Quadriceps Muscle Strength With a Quadriceps Tendon Graft Compared With a Patellar or Hamstring Tendon Graft at 7 Months After Anterior Cruciate Ligament Reconstruction

Holmgren,

Noory,

Moström

et al. 2024

Am J Sports Med

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Background: Impaired quadriceps muscle strength after anterior cruciate ligament reconstruction (ACLR) is associated with worse clinical outcomes and a risk of reinjuries. Yet, we know little about quadriceps muscle strength in patients reconstructed with a quadriceps tendon (QT) graft, which is increasing in popularity worldwide. Purpose: To describe and compare isokinetic quadriceps strength in patients undergoing ACLR with a QT, hamstring tendon (HT), or bone–patellar tendon–bone (BPTB) autograft. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We included patients with QT grafts (n = 104) and matched them to patients with HT (n = 104) and BPTB (n = 104) grafts based on age, sex, and associated meniscal surgery. Data were collected through clinical strength testing at a mean of 7 ± 1 months postoperatively. Isokinetic strength was measured at 90 deg/s, and quadriceps strength was expressed as the limb symmetry index (LSI) for peak torque, total work, torque at 30° of knee flexion, and time to peak torque. Results: Patients with QT grafts had the most impaired isokinetic quadriceps strength, with the LSI ranging between 67.5% and 75.1%, followed by those with BPTB grafts (74.4%-81.5%) and HT grafts (84.0%-89.0%). Patients with QT grafts had a significantly lower LSI for all variables compared with patients with HT grafts (mean difference: peak torque: −17.4% [95% CI, −21.7 to −13.2], P < .001; total work: −15.9% [95% CI, −20.6 to −11.1], P < .001; torque at 30° of knee flexion: −8.8% [95% CI, −14.7 to −2.9], P = .001; time to peak torque: −17.7% [95% CI, −25.8 to −9.6], P < .001). Compared with patients with BPTB grafts, patients with QT grafts had a significantly lower LSI for all variables (mean difference: peak torque: −6.9% [95% CI, −11.2 to −2.7], P < .001; total work: −7.7% [95% CI, −12.4 to −2.9], P < .001; torque at 30° of knee flexion: −6.3% [95% CI, −12.2 to −0.5], P = .03; time to peak torque: −8.8% [95% CI, −16.9 to −0.7], P = .03). None of the graft groups reached a mean LSI of >90% for peak torque (QT: 67.5% [95% CI, 64.8-70.1]; HT: 84.9% [95% CI, 82.4-87.4]; BPTB: 74.4% [95% CI, 72.0-76.9]). Conclusion: At 7 months after ACLR, patients with QT grafts had significantly worse isokinetic quadriceps strength than patients with HT and BPTB grafts. None of the 3 graft groups reached a mean LSI of >90% in quadriceps strength.

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Section: Implications For Rehabilitation and Future Researchsupporting

confidence: 71%

Weaker Quadriceps Muscle Strength With a Quadriceps Tendon Graft Compared With a Patellar or Hamstring Tendon Graft at 7 Months After Anterior Cruciate Ligament Reconstruction

Holmgren,

Noory,

Moström

et al. 2024

Am J Sports Med

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“…Previous studies have raised concern about the development of cyclops lesions and arthrofibrosis after ACLR with QTA. A systematic review by Zhang et al 49 34 reported that BPTB autograft resulted in a statistically significant higher rate of arthrofibrosis than QTA and HTA (10%, 6.3%, and 1.9%, respectively). However, in a 2021 study that included 475 skeletally mature patients (252 HTA, 223 QTA), Schmu ¨cker et al 40 found a non-statistically significant trend for QTA patients to be at higher risk of reoperation due to cyclops lesions when compared with HTA patients (5.0% vs 2.4%, respectively; P = .13).…”

Section: Discussionmentioning

confidence: 99%

Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: 3-Year Clinical and Patient-Reported Outcomes

Cordasco,

Hidalgo Perea,

Uppstrom

et al. 2024

Am J Sports Med

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Background: The rate of anterior cruciate ligament (ACL) rupture in active, skeletally immature patients is increasing. Although hamstring tendon autograft (HTA) was previously deemed the gold standard, recent studies have shown HTA to have a high failure rate in this high-risk population of young competitive athletes, and quadriceps tendon autograft (QTA) has yielded excellent preliminary outcomes in some studies examining this population. Purpose: To evaluate 3-year clinical and patient-reported functional outcomes of primary ACL reconstruction (ACLR) with soft tissue QTA in skeletally immature patients. Study Design: Case series; Level of evidence, 4. Methods: Skeletally immature patients who underwent ACLR with a full-thickness soft tissue QTA were included. Preoperative patient and surgical data were collected. The ACLR technique was selected predicated upon skeletal age and included all-epiphyseal and complete transphyseal techniques. Patients were followed for a minimum of 2 years with successive clinical visits or were contacted via telephone. Patients who did not have minimum 2-year follow-up after 3 contact attempts via telephone were excluded. Information regarding return to sports (RTS) and concomitant or subsequent surgical procedures was collected. Pediatric International Knee Documentation Committee (Pedi-IKDC), Hospital for Special Surgery Functional Activity Brief Scale (HSS Pedi-FABS), and Single Assessment Numeric Evaluation (SANE) scores were collected. Results: Of 85 adolescent patients aged 11.1 to 17.6 years (mean age, 14.1 ± 1.2 years), 2 patients were determined to be lost to follow-up after 3 failed contact attempts. Of the patients included in this study (N = 83), 26 patients (31%) underwent all-epiphyseal and 57 patients (69%) underwent complete transphyseal ACLR. Additionally, 48 patients (58%) underwent concomitant lateral extra-articular tenodesis using the iliotibial band with a modified Lemaire technique. The mean follow-up time was 3.7 ± 1.2 years (range, 2-7 years). Twenty (24%) patients had subsequent surgical procedures, of which 3 (4%) were due to graft failures. At a mean 3-year follow-up, the mean Pedi-IKDC, HSS Pedi-FABS, and SANE scores were 90, 23, and 94 respectively; the RTS rate was 100%; and the rate of RTS at the previous level of performance was 93%. Conclusion: Use of a soft tissue QTA for ALCR in a high-risk skeletally immature population of athletes resulted in excellent postoperative outcomes with low rates of graft failure and high return to sport rates.

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“…Complications following ACL reconstruction (ACLR), can include missed concomitant injuries, tunnel malposition, infection, tunnel osteolysis, fixation failure, fracture, increased knee stiffness, graft site morbidity and thromboembolic events [80]. Knee stiffness, presenting as either loss of extension and/or loss of flexion, is a common presentation following acute ACL injury and reconstruction, resulting in poorer functional outcomes and greater incidence of osteoarthritis [13].…”

Section: Introductionmentioning

confidence: 99%

Persistent knee extension deficits are common after anterior cruciate ligament reconstruction: a systematic review and meta-analysis of randomised controlled trials

Scholes¹,

Ektas²,

Harrison-Brown³

et al. 2023

Knee Surg Sports Traumatol Arthrosc

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PurposeKnee extension deficits complicate recovery from ACL injury and reconstruction; however, the incidence of knee extension loss is not well defined. The aim of this review was to identify the incidence of loss of extension (LOE) following ACL rupture and reconstruction, explore the definitions of knee extension deficits reported and identify prognostic factors affecting LOE incidence. MethodsA systematic search was conducted in Medline, Cochrane Library and PEDro for studies in publication up to November 2021, with no restrictions on publication year. References were screened and assessed for inclusion using predetermined eligibility criteria. Randomised controlled trials (RCTs) that quantified knee angle, loss of extension or incidence of extension deficit were included for quality assessment and data extraction. Statistical summaries were generated and meta‐analyses performed in two parts to examine: (i) the probability of a datapoint being zero incidence compared to a nonzero incidence and (ii) the relationship between the predictors and nonzero LOE incidence. ResultsA sample of 15,494 studies were retrieved using the search criteria, with 53 studies meeting eligibility criteria. The pooled results from 4991 participants were included for analysis, with 4891 participants who had undergone ACLR. The proportion of included studies judged at an overall low risk of bias was small (7.8%). The observed group and study were the most important predictors for whether a datapoint reported an incidence of extension deficit. Time to follow‐up (P < 0.001) and graft type (P = 0.02) were found to have a significant influence on nonzero LOE incidence (%). Covariate adjusted estimates of average LOE indicated 1 in 3 patients presenting with LOE at 12 month follow‐up, reducing to 1 in 4 at 2 years. ConclusionsThis review examined the definitions for the measurement and interpretation of postoperative knee extension and established the trajectory of knee extension deficit after ACL injury and reconstruction. While factors associated with loss of extension were identified, the exact trajectory of knee extension deficits was difficult to infer due to discrepancies in measurement techniques and patient variation. On average, 1 in 3 patients may present with loss of extension of at least 3 degrees at 12‐month follow‐up, decreasing to 1 in 4 at 2 years. These results may be used by clinicians as an upper threshold for acceptable complication rates following ACLR. Future work should focus on LOE as a clinically relevant complication of ACL injury and treatment with appropriate attention to standardisation of definitions, measurements and better understanding of natural history. PROSPERO registration numberCRD42018092295. Level of evidenceLevel I

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Quadriceps Tendon Anterior Cruciate Ligament Reconstruction: A Systematic Review of Postoperative Rehabilitation and Complication Profiles

Cited by 10 publications

References 85 publications

Weaker Quadriceps Muscle Strength With a Quadriceps Tendon Graft Compared With a Patellar or Hamstring Tendon Graft at 7 Months After Anterior Cruciate Ligament Reconstruction

Weaker Quadriceps Muscle Strength With a Quadriceps Tendon Graft Compared With a Patellar or Hamstring Tendon Graft at 7 Months After Anterior Cruciate Ligament Reconstruction

Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: 3-Year Clinical and Patient-Reported Outcomes

Persistent knee extension deficits are common after anterior cruciate ligament reconstruction: a systematic review and meta-analysis of randomised controlled trials

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