Skip to main content

Advertisement

Log in

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

Abstract

Purpose

The aim of this study was to compare isokinetic quadriceps and hamstring muscle strength in patients following anterior cruciate ligament (ACL) reconstruction who received either hamstring (HT) or quadriceps (QT) tendon autografts at two time intervals within the first year after surgery.

Methods

One hundred twenty-four patients, 81 males (age 22.0 ± 6.2 years) and 43 females (age 20.9 ± 8.7 years), participated in this study. ACL reconstruction was performed with either quadriceps tendon autografts (QT; n = 61) or hamstring tendon autografts (HT; n = 63). Two isokinetic muscle strength tests (t1: 5.5 ± 1.2 months; t2: 7.6 ± 1.6 months) were performed at an angular velocity of 60°/s in both the injured and contralateral knees. An independent t test as well as a two-factor analysis of variance with repeated measurements was used. The significance level was set at p < 0.05.

Results

A statistically significant lower knee extensor strength was observed in the QT group within one year after surgery (p < 0.001). Additionally, data showed a significant higher H/Q ratio in QT patients compared to the HT group at t1 (p < 0.001) and t2 (p = 0.001) as well as a significant effect over time (p < 0.001) and interaction effect of time and graft (p = 0.007). Side-to-side values for extensor muscle strength were significantly (p < 0.001) greater in HT graft patients, while QT patients showed significantly (p < 0.001) greater values for flexor muscle strength at both time points of isokinetic testing, respectively.

Conclusion

The results of this study indicate that graft choice has an impact on extensor strength in the first months after ACL reconstruction; however, there is no impact on flexor strength. The finding of a higher H/Q ratio in patients with QT grafts within the first months following surgery is possibly of clinical relevance. This may potentially be associated with lower stress on the maturing ACL graft. Furthermore, normal thigh strength can be restored over time.

Level of evidence

III.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Ageberg E, Roos HP, Silbernagel KG, Thomeé R, Roos EM (2009) Knee extension and flexion muscle power after anterior cruciate ligament reconstruction with patellar tendon graft or hamstring tendons graft: a cross-sectional comparison 3 years post surgery. Knee Surg Sports Traumatol Arthrosc 17:162–169

    Article  PubMed  Google Scholar 

  2. 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–A:2143–2155

    Article  PubMed  Google Scholar 

  3. Alentorn-Geli E, Mendiguchía J, Samuelsson K, Musahl V, Karlsson J, Cugat R, Myer GD (2014) Prevention of anterior cruciate ligament injuries in sports. Part I: systematic review of risk factors in male athletes. Knee Surg Sports Traumatol Arthrosc 22:3–15

    Article  PubMed  Google Scholar 

  4. Alentorn-Geli E, Mendiguchía J, Samuelsson K, Musahl V, Karlsson J, Cugat R, Myer GD (2014) Prevention of non-contact anterior cruciate ligament injuries in sports. Part II: systematic review of the effectiveness of prevention programmes in male athletes. Knee Surg Sports Traumatol Arthrosc 22:16–25

    Article  PubMed  Google Scholar 

  5. Anderson MJ, Browning WM, Urband CE, Kluczynski MA, Bisson LJ (2016) A systematic summary of systematic reviews on the topic of the anterior cruciate ligament. Orthop J Sports Med 4:2325967116634074. doi:10.1177/2325967116634074

    Article  PubMed  PubMed Central  Google Scholar 

  6. Ardern CL, Webster KE, Taylor NF, Feller JA (2010) Hamstring strength recovery after hamstring tendon harvest for anterior cruciate ligament reconstruction: a comparison between graft types. Arthroscopy 26:462–469

    Article  PubMed  Google Scholar 

  7. Beard DJ, Anderson JL, Davies S, Price AJ, Dodd CAF (2001) Hamstrings vs. patella tendon for anterior cruciate ligament reconstruction: a randomised controlled trial. Knee 8:45–50

    Article  CAS  PubMed  Google Scholar 

  8. Beynnon BD, Johnson RJ, Fleming BC, Kannus P, Kaplan M, Samani J, Renstrom P (2002) Anterior cruciate ligament replacement: comparison of bone-patellar tendon-bone grafts with two-strand hamstring grafts. A prospective, randomized study. J Bone Joint Surg Am 84:1503–1513

    Article  PubMed  Google Scholar 

  9. Biau DJ, Tournoux C, Katsahian S, Schranz PJ, Nizard RS (2006) Bone-patellar tendon-bone autografts versus hamstring autografts for reconstruction of anterior cruciate ligament: meta-analysis. BMJ 332:995–1001

    Article  PubMed  PubMed Central  Google Scholar 

  10. 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

    Article  CAS  PubMed  Google Scholar 

  11. Eriksson E (2008) Does harvesting the hamstrings for ACL reconstruction impair the muscular function of the knee joint? Knee Surg Sports Traumatol Arthrosc 16:1

    Article  PubMed  Google Scholar 

  12. Fink C, Herbort M, Abermann E, Hoser C (2014) Minimally invasive harvest of a quadriceps tendon graft with or without a bone block. Arthrosc Tech 3:e509–e513

    Article  PubMed  PubMed Central  Google Scholar 

  13. Gokeler A, Bisschop M, Benjaminse A, Myer GD, Eppinga P, Otten E (2014) Quadriceps function following ACL reconstruction and rehabilitation: implications for optimisation of current practices. Knee Surg Sports Traumatol Arthrosc 22:1163–1174

    Article  PubMed  Google Scholar 

  14. Griffin LY, Albohm MJ, Arendt EA, Bahr R, Beynnon BD, Demaio M, Dick RW, Engebretsen L, Garrett WE, Hannafin JA, Hewett TE, Huston LJ, Ireland ML, Johnson RJ, Lephart S, Mandelbaum BR, Mann BJ, Marks PH, Marshall SW, Myklebust G, Noyes FR, Powers C, Shields C, Shultz SJ, Silvers H, Slauterbeck J, Taylor DC, Teitz CC, Wojtys EM, Yu B (2006) Understanding and preventing noncontact anterior cruciate ligament injuries: a review of the hunt valley II meeting, January 2005. Am J Sports Med 34:1512–1532

    Article  PubMed  Google Scholar 

  15. Heijne A, Werner S (2007) 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 Surg Sports Traumatol Arthrosc 15:402–414

    Article  PubMed  Google Scholar 

  16. Heijne A, Werner S (2010) A 2-year follow-up of rehabilitation after ACL reconstruction using patellar tendon or hamstring tendon grafts: a prospective randomised outcome study. Knee Surg Sports Traumatol Arthrosc 18:805–813

    Article  PubMed  Google Scholar 

  17. Heijne A, Äng BO, Werner S (2009) Predictive factors for 12-month outcome after anterior cruciate ligament reconstruction. Scand J Med Sci Sports 19:842–849

    Article  CAS  PubMed  Google Scholar 

  18. Herbort M, Michel P, Raschke MJ, Vogel N, Schulze M, Zoll A, Fink C, Petersen W, Domnick C (2016) Should the ipsilateral hamstrings be used for anterior cruciate ligament reconstruction in the case of medial collateral ligament insufficiency? Biomechanical investigation regarding dynamic stabilization of the medial compartment by the hamstring muscle. Am J Sports Med. doi:10.1177/0363546516677728

    Google Scholar 

  19. Hewett TE, Myer GD, Ford KR, Heidt RS, Colosimo AJ, McLean SG, van den Bogert AJ, Paterno MV, Succop P (2005) Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med 33:492–501

    Article  PubMed  Google Scholar 

  20. Hewett TE, Myer GD, Ford KR, Paterno MV, Quatman CE (2016) Mechanisms, prediction, and prevention of ACL injuries: cut risk with three sharpened and validated tools. J Orthop Res 34:1843–1855

    Article  PubMed  PubMed Central  Google Scholar 

  21. Iriuchishima T, Ryu K, Okano T, Suruga M, Aizawa S, Fu FH (2016) The evaluation of muscle recovery after anatomical single-bundle ACL reconstruction using a quadriceps autograft. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-016-4124-z

    Google Scholar 

  22. Kanamoto T, Tanaka Y, Yonetani Y, Kita K, Amano H, Kusano M, Hirabayashi S, Horibe S (2015) Anterior knee symptoms after double-bundle ACL reconstruction with hamstring tendon autografts: an ultrasonographic and power Doppler investigation. Knee Surg Sports Traumatol Arthrosc 23:3324–3329

    Article  PubMed  Google Scholar 

  23. Kannus P (1988) Ratio of hamstring to quadriceps femoris muscles’ strength in the anterior cruciate ligament insufficient knee. Relationship to long-term recovery. Phys Ther 68:961–965

    Article  CAS  PubMed  Google Scholar 

  24. Kannus P (1994) Isokinetic evaluation of muscular performance: implications for muscle testing and rehabilitation. Int J Sports Med 15:S11–S18

    Article  PubMed  Google Scholar 

  25. Kim HJ, Lee JH, Ahn SE, Park M-J, Lee DH (2016) Influence of anterior cruciate ligament tear on thigh muscle strength and hamstring-to-quadriceps ratio: a meta-analysis. PLoS ONE 11:e0146234

    Article  PubMed  PubMed Central  Google Scholar 

  26. Landes S, Nyland J, Elmlinger B, Tillett E, Caborn D (2010) Knee flexor strength after ACL reconstruction: comparison between hamstring autograft, tibialis anterior allograft, and non-injured controls. Knee Surg Sports Traumatol Arthrosc 18:317–324

    Article  PubMed  Google Scholar 

  27. Lautamies R, Harilainen A, Kettunen J, Sandelin J, Kujala UM (2008) Isokinetic quadriceps and hamstring muscle strength and knee function 5 years after anterior cruciate ligament reconstruction: comparison between bone-patellar tendon-bone and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc 16:1009–1016

    Article  PubMed  Google Scholar 

  28. Li RC, Maffulli N, Hsu YC, Chan KM (1996) Isokinetic strength of the quadriceps and hamstrings and functional ability of anterior cruciate deficient knees in recreational athletes. Br J Sports Med 30:161–164

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Liebensteiner MC, Krismer M, Koller A, Semenitz B, Mayr E (2012) Does minimally invasive total knee arthroplasty improve isokinetic torque? Clin Orthop Relat Res 470:3233–3239

    Article  PubMed  PubMed Central  Google Scholar 

  30. Magnussen RA, Trojani C, Granan LP, Neyret P, Colombet P, Engebretsen L, Wright RW, Kaeding CC (2015) Patient demographics and surgical characteristics in ACL revision: a comparison of French, Norwegian, and North American cohorts. Knee Surg Sports Traumatol Arthrosc 23:2339–2348

    Article  PubMed  Google Scholar 

  31. Mulford JS, Hutchinson SE, Hang JR (2013) Outcomes for primary anterior cruciate reconstruction with the quadriceps autograft: a systematic review. Knee Surg Sports Traumatol Arthrosc 21:1882–1888

    Article  PubMed  Google Scholar 

  32. Murphy DF, Connolly DAJ, Beynnon BD (2003) Risk factors for lower extremity injury: a review of the literature. Br J Sports Med 37:13–29

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Myer GD, Ford KR, Barber Foss KD, Liu C, Nick TG, Hewett TE (2009) The relationship of hamstrings and quadriceps strength to anterior cruciate ligament injury in female athletes. Clin J Sport Med 19:3–8

    Article  PubMed  Google Scholar 

  34. Neeter C, Gustavsson A, Thomeé P, Augustsson J, Thomeé R, Karlsson J (2006) Development of a strength test battery for evaluating leg muscle power after anterior cruciate ligament injury and reconstruction. Knee Surg Sports Traumatol Arthrosc 14:571–580

    Article  PubMed  Google Scholar 

  35. Palmieri-Smith RM, Thomas AC, Wojtys EM (2008) Maximizing quadriceps strength after ACL reconstruction. Clin Sports Med 27:405–424

    Article  PubMed  Google Scholar 

  36. Papalia R, Franceschi F, D’Adamio S, Diaz Balzani L, Maffulli N, Denaro V (2015) Hamstring tendon regeneration after harvest for anterior cruciate ligament reconstruction: a systematic review. Arthroscopy 31:1169–1183

    Article  PubMed  Google Scholar 

  37. Parkkari J, Kujala UM, Kannus P (2001) Is it possible to prevent sports injuries? Review of controlled clinical trials and recommendations for future work. Sports Med 31:985–995

    Article  CAS  PubMed  Google Scholar 

  38. Rosenberg TD, Franklin JL, Baldwin GN, Nelson KA (1992) Extensor mechanism function after patellar tendon graft harvest for anterior cruciate ligament reconstruction. Am J Sports Med 20:519–525

    Article  CAS  PubMed  Google Scholar 

  39. Sell TC, Ferris CM, Abt JP, Tsai YS, Myers JB, Fu FH, Lephart SM (2007) Predictors of proximal tibia anterior shear force during a vertical stop-jump. J Orthop Res 25:1589–1597

    Article  PubMed  Google Scholar 

  40. Shaerf DA, Pastides PS, Sarraf KM, Willis-Owen CA (2014) Anterior cruciate ligament reconstruction best practice: a review of graft choice. World J Orthop 5:23–29

    Article  PubMed  PubMed Central  Google Scholar 

  41. Sherman OH, Banffy MB (2004) Anterior cruciate ligament reconstruction: which graft is best? Arthroscopy 20:974–980

    Article  PubMed  Google Scholar 

  42. Tsepis E, Vagenas G, Giakas G, Georgoulis A (2004) Hamstring weakness as an indicator of poor knee function in ACL-deficient patients. Knee Surg Sports Traumatol Arthrosc 12:22–29

    Article  CAS  PubMed  Google Scholar 

  43. van Grinsven S, van Cingel REH, Holla CJM, van Loon CJM (2010) Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 18:1128–1144

    Article  PubMed  Google Scholar 

  44. World Medical Association (2013) Declaration of Helsinki. Ethical principles for medical research involving human subjects. JAMA 310:2191–2194

    Article  Google Scholar 

  45. Xergia SA, McClelland JA, Kvist J, Vasiliadis HS, Georgoulis AD (2011) The influence of graft choice on isokinetic muscle strength 4–24 months after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 19:768–780

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The study group would like to thank all of the study participants for their efforts. Thanks to Helmut Pointner for performing the isokinetic testing.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Christian Fink.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest related to this study.

Funding

None.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Fischer, F., Fink, C., Herbst, E. et al. 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 (2018). https://doi.org/10.1007/s00167-017-4522-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-017-4522-x

Keywords

Navigation