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

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Knee 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.

Methods

A 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.

Results

A 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.

Conclusions

This 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 number

CRD42018092295.

Level of evidence

Level I

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Data availability

Data are available from the authors on request.

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Acknowledgements

The authors would like to acknowledge the contribution of Binglong Lee, Mathew Holt, Michael Erian and Christopher Erian for their contribution to paper screening and data extraction, and Milad Ebraihimi for performing the data quality control.

Funding

This manuscript was supported by funding from the Queen Elizabeth II Jubilee Orthopaedic Research Fund; paid to EBM Analytics for assistance with study design and execution.

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Authors and Affiliations

  1. EBM Analytics, Crows Nest, NSW, Australia

    Corey Scholes, Nalan Ektas & Meredith Harrison-Brown

  2. Orthopaedics Department, Queen Elizabeth II Jubilee Hospital, Coopers Plains, QLD, Australia

    Maha Jegatheesan, Ashwin Rajesh & Christopher Bell

  3. Physiotherapy Department, Queen Elizabeth II Jubilee Hospital, Coopers Plains, QLD, Australia

    Garry Kirwan

Authors
  1. Corey Scholes
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  2. Nalan Ektas
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  4. Maha Jegatheesan
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  7. Christopher Bell
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Contributions

GK and CB contributed to the clinical problem. NE and CS contributed to the study objectives and design. NE and MHB designed the screening and data collection processes. CS, NE, MHB, MJ, AR and GK screened the studies for the review, and NE, MHB, MJ and AR collected the data. CS conducted data and statistical analysis, and CS, NE, and CB interpreted the results. NE and CS drafted the manuscript, with contributions from CB, GK and MHB. All authors have reviewed and approved the manuscript.

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Correspondence to Christopher Bell.

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Conflict of interest

NE, CS and MHB report payment to EBM Analytics from the Senior Author for assistance with completion of this study. No other authors have conflicts of interest to report.

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Scholes, C., Ektas, N., Harrison-Brown, M. et al. Persistent knee extension deficits are common after anterior cruciate ligament reconstruction: a systematic review and meta-analysis of randomised controlled trials. Knee Surg Sports Traumatol Arthrosc 31, 3172–3185 (2023). https://doi.org/10.1007/s00167-022-07299-3

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