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Terminal knee extension deficit and female sex predict poorer quadriceps strength following ACL reconstruction using all-soft tissue quadriceps tendon autografts

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The all-soft tissue quadriceps tendon (QT) autograft is becoming increasingly popular for ACL reconstruction (ACLR); however, studies reporting strength recovery and early outcomes after QT autograft are limited with patient samples composed of predominantly males. The primary purpose was to characterize early, sex-specific recovery of strength, range of motion (ROM), and knee laxity in a large cohort of patients undergoing primary ACLR with standardized harvest technique of the all-soft tissue QT autograft. The secondary purpose was to examine the influence of demographic factors and clinical measures on 6-month quadriceps strength.

Methods

Patients 14–25 years who underwent primary, unilateral ACLR with all-soft tissue QT autografts were prospectively followed. Knee laxity and ROM were collected at 6 weeks, 3 and 6 months; while, quadriceps normalized torques and limb symmetry indices (LSI) were collected at 3 and 6 months using isokinetic dynamometry at 60°/s. Two-way ANOVAs with repeated measures were conducted to determine recovery over time and between sexes. Stepwise linear multiple regressions were conducted to determine predictors of 6-month quadriceps strength.

Results

Three-hundred and twenty patients were included (18 ± 3 years; 156 males:164 females; BMI = 24 ± 4 kg/m2) with no early graft failures within the study period. For strength, there were significant main effects of time (p < 0.001) and sex (p < 0.001), indicating similar improvement from 3 to 6 months with males demonstrating greater quadriceps LSI (6 months: 72.1 vs 63.3%) and normalized strength (6 months: 2.0 vs 1.6 Nm/kg). A significantly higher proportion of females had knee extension ROM deficits ≥ 5° compared to males at 6 weeks (61 vs 39%; p = 0.002). Female sex and 3-month extension ROM deficits were identified as significant predictors of 6-month quadriceps LSI (R2 = 0.083; p < 0.001). Female sex, BMI, and 6-week extension ROM deficits were identified as significant predictors of 6-month normalized quadriceps strength (R2 = 0.190; p < 0.001).

Conclusions

Females had decreased quadriceps strength and greater extension ROM deficits at 3 and 6 months following ACLR using all-soft tissue QT autografts. Female sex, higher BMI, and loss of extension ROM were independent predictors of poorer quadriceps strength at 6 months. There were no early graft failures, and laxity remained within normal ranges for both males and females. Surgeons and rehabilitation clinicians should be aware of the increased risk of postoperative loss of extension ROM in females and its implications on quadriceps strength recovery.

Level of evidence

III.

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Acknowledgements

We thank Nikki Bailys, Melanie Insley, Jordan Marks, and Abbey Meisenheimer for their help in the initial preparation of data.

Funding

None.

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Authors and Affiliations

  1. Department of Orthopaedics, School of Medicine, Emory University, 1968 Hawks Lane, Atlanta, GA, 30329, USA

    Jennifer L. Hunnicutt & John W. Xerogeanes

  2. Emory Orthopaedics and Spine Center, Emory Healthcare, Atlanta, USA

    John W. Xerogeanes & Michael Newsome

  3. Department of Physical Therapy, College of Nursing and Health Professions, Georgia State University, Atlanta, USA

    Liang-Ching Tsai

  4. Division of Physical Therapy, School of Medicine, Emory University, Atlanta, USA

    Peter A. Sprague & Mark A. Lyle

  5. Department of Orthopaedics, College of Medicine, Medical University of South Carolina, Charleston, USA

    Harris S. Slone

Authors
  1. Jennifer L. Hunnicutt
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  2. John W. Xerogeanes
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  3. Liang-Ching Tsai
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  4. Peter A. Sprague
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  5. Michael Newsome
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  6. Harris S. Slone
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Contributions

JLH, MAL, JWX oversaw and contributed to all aspects of the project and manuscript development. LT assisted with the statistical analyses. PAS, MN, and HSS assisted with project development and interpretation of the data. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Jennifer L. Hunnicutt.

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Conflict of interest

Dr. Xerogeanes declares conflict of interest (paid consultant for Arthrex and holds patent for device with Arthrex). Dr. Slone declares conflict of interest (editorial board for Am J Orthop and J Surg Orthop Advances).

Ethical approval

Prior to the conduct of this study, the institutional review board of Emory University approved the protocol (IRB #: 00106812).

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Prior to the conduct of this study, the institutional review board approved the protocol and provided a waiver of informed consent.

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Hunnicutt, J.L., Xerogeanes, J.W., Tsai, LC. et al. Terminal knee extension deficit and female sex predict poorer quadriceps strength following ACL reconstruction using all-soft tissue quadriceps tendon autografts. Knee Surg Sports Traumatol Arthrosc 29, 3085–3095 (2021). https://doi.org/10.1007/s00167-020-06351-4

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  • DOI: https://doi.org/10.1007/s00167-020-06351-4

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