Early ACL reconstruction shows an improved recovery of isokinetic thigh muscle strength compared to delayed or chronic cases

Abstract

Introduction: The recovery of periarticular strength is a major criterion in return-to-play testing. The rationale of the study was to assess the impact of the delay of surgery (∆ between injury and surgery) on knee extensor and knee flexor strength of anterior cruciate ligament (ACL)-deficient patients six months after reconstruction.

Materials and methods: In a retrospective cohort study, all patients with ACL ruptures between 03/2015 and 12/2019 were analyzed. Inclusion criteria were isolated ACL rupture without any associated lesions undergoing a reconstruction using ipsilateral hamstring tendon autograft and adherence to isokinetic strength testing before and at 5-7 months postoperatively. These patients were then clustered into three groups: EARLY reconstruction (∆ < 42 days), DELAYED reconstruction (∆42-180d), and CHRONIC (∆ > 180d). Knee extensor and flexor strength of the ipsi- and contralateral leg were analyzed by concentric isokinetic measurement (60°/s). Primary outcomes were the maximal knee extension and flexion torque, hamstrings-to-quadriceps ratio (H/Q) ratio), and the corresponding limb symmetry indices.

Results: n = 444 patients met the inclusion criteria. From EARLY to DELAYED to CHRONIC, a progressive reduction in postoperative strength performance was observed in knee extension (1.65 ± 0.45 to 1.62 ± 0.52 to 1.51 ± 0.5 Nm/kg resp.) and flexion (1.22 ± 0.29 to 1.18 ± 0.3 to 1.13 ± 0.31 Nm/kg resp.) strength on the ACL reconstructed leg. This general loss in periarticular strength was already apparent in the preoperative performance even on the healthy side. When controlling for the preoperative performance using ANCOVA analysis, EARLY performed significantly better than DELAYED (extension p = 0.001, flexion p = .02) and CHRONIC (extension p = 0.005, flexion p < 0.001). Also, there were significantly higher values for H/Q ratio in the injured leg across all groups where the H/Q ratio increased from EARLY to CHRONIC and from pre- to postoperative values.

Conclusions: With respect to the force generating capacity when returning-to-play, it is advantageous to seek for an early ACL reconstruction within the first 12 weeks after the injury. The increasing loss of thigh muscle strength observed in delayed or chronic cases affects the injured and also the non-injured leg.

Level of evidence: III, retrospective cohort study.

Keywords: ACL reconstruction; Isokinetic strength; Return-to-sports; Timing of surgery.

Fig. 1

Setup for isokinetic strength testing

Fig. 2

Study flow chart diagram

Fig. 3

Limb symmetry indices across the groups from pre- to postoperative values, * = p < 0.05, for standard deviations, see Tables 2 and 3

Fig. 4

Pre-operative isokinetic strength of the healthy leg across the groups. *Referring to the limb symmetry index and significant differences at p < 0.05

Fig. 5

H/Q ratio across the groups and change from pre- to postoperative values * = p < 0.05, for standard deviations, see Tables 2 and 3

Fig. 6

Post-operative isokinetic strength of the ACL reconstructed leg across the groups, * = p < 0.05