Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts: a prospective randomized outcome study

Knee

Abstract

The purpose of the present investigation was to evaluate physical outcome after anterior cruciate ligament (ACL) reconstruction with early versus late initiation of open kinetic chain (OKC) exercises for the quadriceps in patients operated on either patellar tendon or hamstring grafts. Sixty-eight patients, 36 males and 32 females, with either patellar tendon graft (34 patients) or hamstring graft (34 patients) were enrolled in this study. All patients were randomly allocated to either early (the 4th postoperative week) or late (the 12th postoperative week) start of OKC exercises for the quadriceps, resulting in four subgroups: patellar tendon reconstruction, early start (P4) or late start (P12) of OKC quadriceps exercises, hamstring tendon reconstruction, early start (H4) or late start (H12) of quadriceps OKC exercises. Prior to surgery and 3, 5 and 7 months later, assessments of range of motion (goniometer), anterior knee laxity (KT-1000), postural sway (KAT 2000), thigh muscle torques (Kin–Com dynamometer) and anterior knee pain (anterior knee pain score) were evaluated. No significant group differences were found in terms of range of motion 3, 5 and 7 months postoperatively. The H4 group showed a significantly higher mean difference of laxity over time of 1.0 mm (CI: 0.18–1.86) than the P4 group (= 0.04). Within the same type of surgery, the H4 against the H12, the mean difference over time was 1.2 mm (0.37–2.1) higher in the H4 group than in the H12 group (= 0.01). There were no significant group differences in terms of postural sway or anterior knee pain at the different test occasions. Significant differences in trends (changes over time) were found when comparing the four groups, for both quadriceps muscle torques (< 0.001) and hamstring muscle torques (P < 0.001). All groups, except the P4 group, reached preoperative values of quadriceps muscle torques at the 7 months follow-up. In the H4 and the H12 groups, significantly lower hamstring muscle torques at the 7 months follow-up compared with preoperative values were found. In conclusion, early start of OKC quadriceps exercises after hamstring ACL reconstruction resulted in significantly increased anterior knee laxity in comparison with both late start and with early and late start after bone–patellar tendon–bone ACL reconstruction. Furthermore, the early introduction of OKC exercises for quadriceps did not influence quadriceps muscle torques neither in patients operated on patellar tendon nor hamstring tendon grafts. On the contrary, it appears as if the choice of graft affected the strength of the specific muscle more than the type of exercises performed. Our results could not determine the appropriate time for starting OKC quadriceps exercises for patients who have undergone ACL reconstruction with hamstring tendon graft. Future studies of long-term results of anterior knee laxity and functional outcome are needed.

Keywords

ACL rehabilitation Knee laxity Muscle strength Physical outcome 

References

  1. 1.
    Aglietti P, Giron F, Buzzi R, Biddau F, Sasso F (2004) Anterior cruciate ligament reconstruction: bone–patellar tendon–bone compared with double semitendinosus and gracilis tendon grafts. A prospective randomized clinical trial. J Bone Joint Surg Am 86:2143–2155PubMedGoogle Scholar
  2. 2.
    Anderson AF, Snyder RB, Lipscomb AB Jr (2001) Anterior cruciate ligament reconstruction. A prospective randomized study of three surgical methods. Am J Sports Med 29:272–279PubMedGoogle Scholar
  3. 3.
    Augustsson J, Thomeé R (2000) Ability of closed and open kinetic chain tests of muscular strength to assess functional performance. Scand J Med Sci Sports 10:164–168PubMedCrossRefGoogle Scholar
  4. 4.
    Augustsson J, Thomeé R, Linden C, Folkesson M, Tranberg R, Karlsson J (2006) Single-leg hop testing following fatiguing exercise: reliability and biomechanical analysis. Scand J Med Sci Sports 16:111–120PubMedCrossRefGoogle Scholar
  5. 5.
    Aune AK, Holm I, Risberg MA, Jensen HK, Steen H (2001) Four-strand hamstring tendon autograft compared with patellar tendon–bone autograft for anterior cruciate ligament reconstruction. A randomized study with two year follow-up. Am J Sports Med 29:722–728PubMedGoogle Scholar
  6. 6.
    Barrack RL, Skinner HB, Buckley SL (1989) Proprioception in the anterior cruciate deficient knee. Am J Sports Med 17:1–6PubMedGoogle Scholar
  7. 7.
    Beynnon BD, Uh BS, Johnson RJ, Abate JA, Nichols CE, Fleming BC, Poole AR, Roos H (2005) Rehabilitation after anterior cruciate ligament reconstruction: a prospective randomized double-blind comparison of programs administered over 2 different time intervals. Am J Sports Med 33:347–359PubMedCrossRefGoogle Scholar
  8. 8.
    Bodor M (2001) Quadriceps protects the anterior cruciate ligament. J Orthop Res 19:629–633PubMedCrossRefGoogle Scholar
  9. 9.
    Bynum EB, Barrack RL, Alexander AH (1995) Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction. A prospective randomized study. Am J Sports Med 23:401–406PubMedGoogle Scholar
  10. 10.
    Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA (1999) Arthroscopic reconstruction of the anterior cruciate ligament. A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. Am J Sports Med 27:444–454PubMedGoogle Scholar
  11. 11.
    Daniel DM, Stone ML, Sachs R, Malcom L (1985) Instrumented measurement of anterior knee laxity in patients with acute anterior cruciate ligament disruption. Am J Sports Med 13:401–407PubMedGoogle Scholar
  12. 12.
    Ejerhed L, Kartus J, Sernert N, Köhler K, Karlsson J (2003) Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction? A prospective randomized study with a two-year follow-up. Am J Sports Med 31:19–25PubMedGoogle Scholar
  13. 13.
    Ekstrand J, Wiktorsson M, Öberg B, Gillquist J (1982) Lower extremity goniometric measurements: a study to determine their reliability. Arch Phys Med Rehabil 63:171–175PubMedGoogle Scholar
  14. 14.
    Eriksson K, Anderberg P, Hamberg P, Löfgren AC, Bredenberg M, Westman I, Wredmark T (2001) A comparison of quadruple semitendinosus and patellar tendon grafts in reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br 83:348–354PubMedCrossRefGoogle Scholar
  15. 15.
    Farrell M, Richards JG (1986) Analysis of the reliability and validity of the kinetic communicator exercise device. Med Sci Sports Exerc 18:180–185Google Scholar
  16. 16.
    Feller JA, Webster KE (2003) A randomized comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction. Am J Sports Med 31:564–573PubMedGoogle Scholar
  17. 17.
    Fleck SJ, Kraemer WJ (1997) Designing resistance training programs, 2nd edn. Champaign (IL) human kinetics, pp 131–163Google Scholar
  18. 18.
    Fleming BC, Ohlen G, Renström PA, Peura GD, Beynnon BD, Badger GJ (2003) The effects of compressive load and knee joint torque on peak anterior cruciate ligament strains. Am J Sports Med 31:701–707PubMedGoogle Scholar
  19. 19.
    Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC (2005) Reconstruction of the anterior cruciate ligament: metaanalysis of patellar tendon versus hamstring g tendon autograft. Arthroscopy 21:791–803PubMedCrossRefGoogle Scholar
  20. 20.
    Gransberg L, Knutsson E (1983) Determination of dynamic muscle strength in man with acceleration controlled isokinetic movements. Acta Physiol Scand 119:317–320PubMedCrossRefGoogle Scholar
  21. 21.
    Hansen MS, Dieckmann B, Jensen K, Jakobsen BW (2000) The reliability of balance tests performed on the kinaesthetic ability trainer (KAT 2000). Knee Surg Sports Trauma Arthrosc 8:180–185CrossRefGoogle Scholar
  22. 22.
    Hantes ME, Mastrokalos DS, Yu J, Pässler HH (2004) The effect of early motion on tibial tunnel widening after anterior cruciate ligament replacement using hamstring tendon grafts. Arthroscopy 20(6):572–580PubMedCrossRefGoogle Scholar
  23. 23.
    Hefti F, Müller W, Jakob RP, Staubli HU (1993) Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1:226–234PubMedCrossRefGoogle Scholar
  24. 24.
    Hefti F, Müller W (1993) Current state of evaluation of knee ligament lesions. The new IKDC knee evaluation form. Orthopaede 22:351–362Google Scholar
  25. 25.
    Hooper DM, Morrissey MC, Drechsler W, Morrissey D, King J (2001) Open and closed kinetic chain exercises in the early period after anterior cruciate ligament reconstruction. Improvements in level walking, stair ascent, and stair descent. Am J Sports Med 29:167–174PubMedGoogle Scholar
  26. 26.
    Hughes G, Watkins J (2006) A risk-factor model for anterior cruciate ligament injury. Sports Med 36:411–428PubMedCrossRefGoogle Scholar
  27. 27.
    Isberg J, Faxén E, Brandsson S, Eriksson BI, Kärrholm J, Karlsson J (2006) Early active extension after anterior cruciate ligament reconstruction does not result in increased laxity of the knee. Knee Surg Sports Trauma Arthrosc 2006 (on-line publication)Google Scholar
  28. 28.
    Johnson RJ, Beynnon BD (1995) Rehabilitation following anterior cruciate ligament reconstruction: what do we really know? Iowa Orthop J 15:19–23PubMedGoogle Scholar
  29. 29.
    Kartus J, Magnusson L, Stener S, Brandsson S, Eriksson BI, Karlsson J (1999) Complications following arthroscopic anterior cruciate ligament reconstruction. A 2–5 year follow-up of 604 patients with special emphasis on anterior knee pain. Knee Surg Sports Trauma Arthrosc 7:2–8CrossRefGoogle Scholar
  30. 30.
    Kartus J, Movin T, Karlsson J (2001) Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts. Arthroscopy 17:971–980PubMedCrossRefGoogle Scholar
  31. 31.
    Knutsson E, Martensson A (1985) Isokinetic measurements of muscle strength in hysterical paresis. EEG Clin Neurophysiol 61:370–374CrossRefGoogle Scholar
  32. 32.
    Laxdal G, Kartus J, Hansson L, Heidvall M, Ejerhed L, Karlsson J (2005) A prospective randomized comparison of bone–patellar tendon–bone and hamstring grafts for anterior cruciate ligament reconstruction. Arthroscopy 21:34–42PubMedCrossRefGoogle Scholar
  33. 33.
    MacDonald PB, Hedden D, Pacin O, Sutherland K (1996) Proprioception in anterior cruciate ligament-deficient and reconstructed knees. Am J Sports Med 24:774–778PubMedGoogle Scholar
  34. 34.
    Marder RA, Raskind JR, Carroll M (1991) Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstructiom. Patellar tendon versus semitendinosus and gracilis tendons. Am J Sports Med 19:478–484PubMedGoogle Scholar
  35. 35.
    Mikkelsen C, Werner S, Eriksson E (2000) Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Surg Sports Trauma Arthrosc 8:337–342CrossRefGoogle Scholar
  36. 36.
    O’Neill DB (1996) Arthroscopically assisted reconstruction of the anterior cruciate ligament. A prospective randomized analysis of three techniques. J Bone Joint Surg Am 78:803–813PubMedGoogle Scholar
  37. 37.
    Pfeifer K, Banzer W (1999) Motor performance in different dynamic tests I kee rehabilitation. Scand J Med Sci Sports 9:19–27PubMedCrossRefGoogle Scholar
  38. 38.
    Risberg MA, Holm I, Tjomsland O, Ljunggren E, Ekeland A (1999) Prospective study of changes in impairments and disabilities after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 29:400–412PubMedGoogle Scholar
  39. 39.
    Roe J, Pinczewski LA, Russell VJ, Salmon LJ, Kawamata T, Chew M (2005) A 7-year follow-up of patellar tendon and hamstring tendon grafts for arthroscopic anterior cruciate ligament reconstruction: differences and similarities. Am J Sports Med 33:1337–1345PubMedCrossRefGoogle Scholar
  40. 40.
    Sernert N, Kartus JT Jr, Ejerhed L, Karlsson J (2004) Right and left knee laxity measurements: a prospective study of patients with anterior cruciate ligament injuries and normal control subjects. Arthroscopy 20:564–571PubMedCrossRefGoogle Scholar
  41. 41.
    Shaw T, Williams MT, Chipchase LS (2005) Do early quadriceps exercises affect the outcome of ACL reconstruction? A randomised controlled trial. Aust J Physiother 51:9–17PubMedGoogle Scholar
  42. 42.
    Shelbourne KD, Trumper RV (1997) Preventing anterior knee pain after anterior cruciate ligament reconstruction. Am J Sports Med 25:41–47PubMedGoogle Scholar
  43. 43.
    Svensson M, Sernert N, Ejerhed L, Karlsson J, Kartus JT (2006) A prospective comparison of bone–patellar tendon–bone and hamstring grafts for anterior crucoate ligament reconstruction in female patients. Knee Surg Sports Trauma Arthrosc 14:278–286CrossRefGoogle Scholar
  44. 44.
    Werner S, Arvidsson H, Arvidsson I, Eriksson E (1993) Electrical stimulation of vastus medialis and stretching of lateral thigh muscles in patients with patello-femoral symptoms. Knee Surg Sports Trauma Arthrosc 1:85–92CrossRefGoogle Scholar
  45. 45.
    Werner S (1995) An evaluation of knee extensor and knee flexor torques and EMGs in patients with patellofemoral pain syndrome in comparison with matched controls. Knee Surg Sports Traumat Arthrosc 3:89–94CrossRefGoogle Scholar
  46. 46.
    Wroble RR, Van Ginkel LA, Grood ES, Noyes FR, Shaffer BL (1990) Repeatability of the KT-1000 arthrometer in a normal population. Am J Sports Med 18:396–399PubMedGoogle Scholar
  47. 47.
    Yunes M, Richmond JC, Engels EA, Pinczewski LA (2001) Patellar versus hamstring tendons in anterior cruciate ligament reconstruction: a meta-analysis. Arthroscopy 17:248–257PubMedCrossRefGoogle Scholar
  48. 48.
    Zätterstrom R, Fridén T, Lindstrand A, Moritz U (1994) The effect of physiotherapy on standing balance in chronic anterior cruciate ligament insufficiency. Am J Sports Med 22:531–536PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  1. 1.Section of Orthopaedics and Sports Medicine, Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
  2. 2.Capio Artro Clinic, Stockholm Sports Trauma Research CenterKarolinska InstitutetStockholmSweden

Personalised recommendations