Abstract
Purpose
The aim was to assess the consequences of quadriceps tendon (QT) harvest on knee extensor strength after anterior cruciate ligament reconstruction (ACL-R) compared to hamstring tendon (HT) autograft. Secondary objectives were to evaluate flexor strength recovery and search for correlation between strength status and functional outcome.
Methods
This a retrospective cohort of 44 patients who underwent ACL-R using either QT (25) or HT (19). Median age was 31.1 years. We assessed thigh muscle strength thanks to concentric iso kinetic evaluation (peak torque) at 60°.s−1, 180°.s−1, 240°.s−1 and eccentric at 30°.s−1, 7 months on average after surgery. Muscle strength values were compared to the uninjured leg in order to calculate a percentage of deficit as well as unilateral hamstring/quadriceps (H/Q) ratios. KOOS score was obtained at a mean follow-up of 18 months.
Results
Extensor strength deficit (concentric 60°.s−1) was one average 33.1% in the QT group and 28.2% in the HT group (p = 0.42). Difference of flexor strength deficit (concentric 60°.s−1) was close to be significant with 5% and 12% of deficit in the QT and HT group, respectively (p = 0.1), and statistically significant for high angular velocity (14% versus 3% at 240°.s−1, p = 0.04). H/Q ratios were comparable in both groups ranging from 0.62 to 0.78. Quadriceps muscle strength deficit was negatively correlated with the KOOS score (Pearson coefficient = −0.4; p = 0.005).
Conclusion
QT autograft harvest does not yield significant quadriceps muscle weakness after ACL-R, which appear to be a pejorative factor for functional outcome.
Level of evidence
IV, Retrospective study.
Similar content being viewed by others
References
MacIntosh DL (1974) The anterior cruciate ligament. Over the top repair. J Bone Joint Surg 56:591
Marshall JL, Warren RF, Wickiewicz TL, Reider B (1979) The anterior cruciate ligament: a technique of repair and reconstruction. Clin Orthop Relat Res 143:97–106
Blauth W (1984) 2-strip substitution-plasty of the anterior cruciate ligament with the quadriceps tendon. Unfallheilkunde 87:45–51
Stäubli HU, Schatzmann L, Brunner P et al (1999) Mechanical tensile properties of the quadriceps tendon and patellar ligament in young adults. Am J Sports Med 27:27–34. https://doi.org/10.1177/03635465990270011301
Stäubli HU, Schatzmann L, Brunner P et al (1996) Quadriceps tendon and patellar ligament: cryosectional anatomy and structural properties in young adults. Knee Surg Sports Traumatol Arthrosc 4:100–110. https://doi.org/10.1007/bf01477262
Stäubli HU, Jakob RP (1997) Central quadriceps tendon for anterior cruciate ligament reconstruction. Part I: morphometric and biochemical evaluation. Am J Sports Med 25:725–727
Mouarbes D, Menetrey J, Marot V et al (2019) Anterior cruciate ligament reconstruction: a systematic review and meta-analysis of outcomes for quadriceps tendon autograft versus bone-patellar tendon-bone and hamstring-tendon autografts. Am J Sports Med 47:3531–3540. https://doi.org/10.1177/0363546518825340
Hurley ET, Calvo-Gurry M, Withers D et al (2018) Quadriceps tendon autograft in anterior cruciate ligament reconstruction: a systematic review. Arthroscopy 34:1690–1698. https://doi.org/10.1016/j.arthro.2018.01.046
Lubowitz JH (2016) Editorial commentary: quadriceps tendon autograft use for anterior cruciate ligament reconstruction predicted to increase. Arthroscopy 32:76–77. https://doi.org/10.1016/j.arthro.2015.11.004
Sheean AJ, Musahl V, Slone HS et al (2018) Quadriceps tendon autograft for arthroscopic knee ligament reconstruction: use it now, use it often. Br J Sports Med 52:698–701. https://doi.org/10.1136/bjsports-2017-098769
Xerogeanes JW (2019) Quadriceps tendon graft for anterior cruciate ligament reconstruction: the graft of the future! Arthroscopy 35:696–697. https://doi.org/10.1016/j.arthro.2019.01.011
Ajrawat P, Dwyer T, Whelan D et al (2019) A comparison of quadriceps tendon autograft with bone-patellar tendon-bone autograft and hamstring tendon autograft for primary anterior cruciate ligament reconstruction: a systematic review and quantitative synthesis. Clin J Sport Med. https://doi.org/10.1097/JSM.0000000000000765
Mouarbes D, Dagneaux L, Olivier M et al (2020) Lower donor-site morbidity using QT autografts for ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-020-05873-1
Lind M, Strauss MJ, Nielsen T, Engebretsen L (2019) Quadriceps tendon autograft for anterior cruciate ligament reconstruction is associated with high revision rates: results from the danish knee ligament registry. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-019-05751-5
Lee JK, Lee S, Lee MC (2016) Outcomes of anatomic anterior cruciate ligament reconstruction: bone-quadriceps tendon graft versus double-bundle hamstring tendon graft. Am J Sports Med 44:2323–2329. https://doi.org/10.1177/0363546516650666
Cavaignac E, Coulin B, Tscholl P et al (2017) Is quadriceps tendon autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? a comparative study with a mean follow-up of 3.6 years. Am J Sports Med 45:1326–1332. https://doi.org/10.1177/0363546516688665
Hunnicutt JL, Gregory CM, McLeod MM et al (2019) Quadriceps recovery after anterior cruciate ligament reconstruction with quadriceps tendon versus patellar tendon autografts. Orthop J Sports Med 7:2325967119839786. https://doi.org/10.1177/2325967119839786
Sinding KS, Nielsen TG, Hvid LG et al (2020) Effects of autograft types on muscle strength and functional capacity in patients having anterior cruciate ligament reconstruction: a randomized controlled trial. Sports Med. https://doi.org/10.1007/s40279-020-01276-x
Williams GN, Chmielewski T, Rudolph K et al (2001) Dynamic knee stability: current theory and implications for clinicians and scientists. J Orthop Sports Phys Ther 31:546–566. https://doi.org/10.2519/jospt.2001.31.10.546
Cvjetkovic DD, Bijeljac S, Palija S et al (2015) Isokinetic testing in evaluation rehabilitation outcome after ACL reconstruction. Med Arch 69:21–23. https://doi.org/10.5455/medarh.2015.69.21-23
Martin-Alguacil JL, Arroyo-Morales M, Martín-Gomez JL et al (2018) Strength recovery after anterior cruciate ligament reconstruction with quadriceps tendon versus hamstring tendon autografts in soccer players: a randomized controlled trial. Knee 25:704–714. https://doi.org/10.1016/j.knee.2018.03.011
Pigozzi F, Di Salvo V, Parisi A et al (2004) Isokinetic evaluation of anterior cruciate ligament reconstruction: quadriceps tendon versus patellar tendon. J Sports Med Phys Fitness 44:288–293
Kwak Y-H, Lee S, Lee MC, Han H-S (2018) Anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone allograft: matched case control study. BMC Musculoskelet Disord 19:45. https://doi.org/10.1186/s12891-018-1959-0
Fischer F, Fink C, Herbst E et al (2018) Higher hamstring-to-quadriceps isokinetic strength ratio during the first post-operative months in patients with quadriceps tendon compared to hamstring tendon graft following ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 26:418–425. https://doi.org/10.1007/s00167-017-4522-x
Undheim MB, Cosgrave C, King E et al (2015) Isokinetic muscle strength and readiness to return to sport following anterior cruciate ligament reconstruction: is there an association? A systematic review and a protocol recommendation. Br J Sports Med 49:1305–1310. https://doi.org/10.1136/bjsports-2014-093962
Colombet P, Graveleau N (2015) An anterior cruciate ligament reconstruction technique with 4-strand semitendinosus grafts, using outside-in tibial tunnel drilling and suspensory fixation devices. Arthrosc Tech 4:e507-511. https://doi.org/10.1016/j.eats.2015.05.014
Salavati M, Akhbari B, Mohammadi F et al (2011) Knee injury and Osteoarthritis Outcome Score (KOOS); reliability and validity in competitive athletes after anterior cruciate ligament reconstruction. Osteoarthr Cartil 19:406–410. https://doi.org/10.1016/j.joca.2011.01.010
Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49
Pua YH, Bryant AL, Steele JR et al (2008) Isokinetic dynamometry in anterior cruciate ligament injury and reconstruction. Ann Acad Med Singap 37:330–340
Dauty M, Tortellier L, Rochcongar P (2005) Isokinetic and anterior cruciate ligament reconstruction with hamstrings or patella tendon graft: analysis of literature. Int J Sports Med 26:599–606. https://doi.org/10.1055/s-2004-821342
Bryant AL, Kelly J, Hohmann E (2008) Neuromuscular adaptations and correlates of knee functionality following ACL reconstruction. J Orthop Res 26:126–135. https://doi.org/10.1002/jor.20472
Konishi Y, Fukubayashi T, Takeshita D (2002) Possible mechanism of quadriceps femoris weakness in patients with ruptured anterior cruciate ligament. Med Sci Sports Exerc 34:1414–1418. https://doi.org/10.1097/00005768-200209000-00003
Sonnery-Cottet B, Freychet B, Murphy CG et al (2014) Anterior cruciate ligament reconstruction and preservation: the Single-Anteromedial Bundle Biological Augmentation (SAMBBA) technique. Arthrosc Tech 3:e689-693. https://doi.org/10.1016/j.eats.2014.08.007
Snyder-Mackler L, De Luca PF, Williams PR et al (1994) Reflex inhibition of the quadriceps femoris muscle after injury or reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am 76:555–560. https://doi.org/10.2106/00004623-199404000-00010
Breitfuss H, Fröhlich R, Povacz P et al (1996) The tendon defect after anterior cruciate ligament reconstruction using the midthird patellar tendon—a problem for the patellofemoral joint? Knee Surg Sports Traumatol Arthrosc 3:194–198. https://doi.org/10.1007/bf01466615
Yasuda K, Ohkoshi Y, Tanabe Y, Kaneda K (1991) Muscle weakness after anterior cruciate ligament reconstruction using patellar and quadriceps tendons. Bull Hosp Jt Dis Orthop Inst 51:175–185
Wilk KE, Romaniello WT, Soscia SM et al (1994) The relationship between subjective knee scores, isokinetic testing, and functional testing in the ACL-reconstructed knee. J Orthop Sports Phys Ther 20:60–73. https://doi.org/10.2519/jospt.1994.20.2.60
Condouret J, Cohn J, Ferret J-M et al (2008) Isokinetic assessment with two years follow-up of anterior cruciate ligament reconstruction with patellar tendon or hamstring tendons. Rev Chir Orthop Reparatrice Appar Mot 94:375–382. https://doi.org/10.1016/j.rco.2008.09.006
Tourville TW, Jarrell KM, Naud S et al (2014) Relationship between isokinetic strength and tibiofemoral joint space width changes after anterior cruciate ligament reconstruction. Am J Sports Med 42:302–311. https://doi.org/10.1177/0363546513510672
Sapega AA (1990) Muscle performance evaluation in orthopaedic practice. J Bone Joint Surg Am 72:1562–1574
Funding
No funding was needed for this study.
Author information
Authors and Affiliations
Contributions
CH and BRD performed data extraction. MO, JC and RP designed the protocol. MO performed statistical analysis. AM performed the isokinetic tests. CH wrote the initial draft and edited the different versions of the draft. CH, BRD, AM, RP, JC and MO approved the submitted and final version.
Corresponding author
Ethics declarations
Conflict of interest
MO (Matthieu Ollivier) is an educational consultant for Stryker, New-clip and Arthrex. Other authors declare no conflict of interest.
Ethical approval
Study ethics approval was obtained on 19/05/2020 (CECIC Rhône-Alpes-Auvergne, IRB 5891).
Consent to participate
All patients included gave their informed consent. Data collection started after registration to the CNIL France (National commission for Data Protection and Liberties).
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Horteur, C., Rubens Duval, B., Merlin, A. et al. Comparison of knee extensor strength after anterior cruciate ligament reconstruction using either quadriceps tendon or hamstring tendon autografts. Eur J Orthop Surg Traumatol 32, 857–865 (2022). https://doi.org/10.1007/s00590-021-03062-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00590-021-03062-5