Cartilage damage at the time of anterior cruciate ligament reconstruction is associated with weaker quadriceps function and lower risk of future ACL injury

  • Joshua S. Everhart
  • Alex C. DiBartola
  • Katherine Swank
  • Robert Pettit
  • Langston Hughes
  • Caroline Lewis
  • David C. FlaniganEmail author



To determine whether articular cartilage damage noted at the time of primary anterior cruciate ligament reconstruction (ACLR) affects the likelihood of achieving ≥ 90% symmetry for isokinetic extension strength at 6 months after surgery or risk of recurrent ACL injury.


Five hundred and eight patients underwent primary ACLR and diagnostic arthroscopy. All identified cartilage lesions were graded using the Outerbridge system. All patients underwent isokinetic strength testing. The association between cartilage Outerbridge grade and a ≥ 90% Limb Symmetry Index (LSI) and recurrent ACL injury risk at mean 38.7 month follow-up (SD 31.8) was evaluated via multivariate regression analysis.


Grade 2 or higher damage was present in 394 (77.5%) of patients, grade 3 or higher in 143 (28.1%) and grade 4 in 83 (16.4%) at time of ACLR. Ipsilateral ACLR graft rupture occurred in 31 (6.1%) of patients. Contralateral ACL injury occurred in 19 (3.7%). Patients with grade 2 or higher damage were significantly less likely to meet an LSI goal of ≥ 90% for fast (300°/s) isokinetic extension. There was no association with slow isokinetic extension. Cartilage lesion severity at or beyond grade 2 had a similar effect on isokinetic testing results regardless of compartment involvement or performance of microfracture. Patients with grade 2–4 cartilage damage were less likely to sustain a second ipsilateral ACL injury or a contralateral native ACL injury.


Cartilage damage seen at time of ACL reconstruction is common and associated with lower likelihood of achieving ≥ 90% symmetry for isokinetic extension strength at 6 months after surgery. However, lower recurrent ACL injury rates are seen in patients with concurrent cartilage damage. These data may inform future clinical decisions regarding operative managment of recurrent ACL injuries.

Level of evidence



ACL injury Knee cartilage defects Isokinetic strength testing Quadriceps atrophy Return to sport 



No funding was received for this study.

Compliance with ethical standards

Conflict of interest

The authors received no funding for this study and report no conflicts of interest.

Ethical approval

This project was approved by the Biomedical Institutional Research Board of The Ohio State University.


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.Department of OrthopaedicsThe Ohio State University Wexner Medical CenterColumbusUSA
  2. 2.Department of Orthopaedic SurgeryBeaumont HospitalRoyal OakUSA
  3. 3.College of MedicineThe Ohio State UniversityColumbusUSA
  4. 4.Department of Physical Therapy and RehabilitationThe Ohio State University Wexner Medical CenterColumbusUSA
  5. 5.Sports Medicine Research InstituteThe Ohio State University Wexner Medical CenterColumbusUSA

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