Linköping University Post Print

The influence of graft choice on isokinetic

muscle strength 4-24 months after anterior
cruciate ligament reconstruction

Sofia A Xergia, Jodie A McClelland, Joanna Kvist,

Haris S Vasiliadis and Anastasios D Georgoulis

N.B.: When citing this work, cite the original article.

The original publication is available at www.springerlink.com:

Sofia A Xergia, Jodie A McClelland, Joanna Kvist, Haris S Vasiliadis and Anastasios D
Georgoulis, The influence of graft choice on isokinetic muscle strength 4-24 months after
anterior cruciate ligament reconstruction, 2011, KNEE SURGERY SPORTS
TRAUMATOLOGY ARTHROSCOPY, (19), 5, 768-780.
http://dx.doi.org/10.1007/s00167-010-1357-0
Copyright: Springer Science Business Media
http://www.springerlink.com/

Postprint available at: Linköping University Electronic Press

http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-67964
Manuscript
Click here to download Manuscript: ACL SR revision 2.doc Click here to view linked References

1 The influence of graft choice on isokinetic muscle strength 4-24 months after
1
2 2 anterior cruciate ligament reconstruction.
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5 3
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7 4 Sofia A Xergia RPT 1, Jodie A McClelland RPT 2,3
, Joanna Kvist RPT4, Haris S
8
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10 5 Vasiliadis MD1,5, Anastasios D Georgoulis MD1
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12 6
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14 1
15 7 Orthopaedic Sports Medicine Center of Ioannina, Department of Orthopaedic
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17 8 Surgery, University of Ioannina, Greece
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19 2
9 Musculoskeletal Research Centre, La Trobe University, Melbourne, Australia
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21 3
22 10 Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
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24 4
11 Division of Physiotherapy, Department of Medical and Health Sciences, Linköping
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27 12 University, Linköping, Sweden
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29 5
13 Molecular Cell Biology and Regenerative Medicine, Sahlgrenska Academy,
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32 14 University of Gothenburg, Sweden
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34 15
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39 17 Correspondence to:
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41 18 Anastasios D. Georgoulis, MD,
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44 19 Orthopaedic Sports Medicine Center
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46 20 Ioannina, 45110, Greece
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49 21 PO BOX 1042
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51 22 Email: georgoulis@osmci.gr
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54 23 TEL/FAX: (+30) 26510-64980
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 25 Abstract
1
2 26 Purpose: Regaining adequate strength of the quadriceps and hamstrings after anterior
3
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5 27 cruciate ligament (ACL) reconstruction is important for maximizing functional
6
7 28 performance. However, the outcome of muscle strength after either BPTB or
8
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10 29 hamstrings autograft is unclear given the plethora of published studies that report
11
12 30 post-operative muscle strength. The purpose of this study was to systematically
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15 31 compare the muscle strength of patients who have undergone ACL reconstruction
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17 32 using either Bone Patellar Tendon Bone (BPTB) or Hamstrings (HST) autograft.
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33 Methods: The databases of MEDLINE, Cinahal and EMBASE were systematically
20
21
22 34 searched for articles that report muscle strength outcome following ACL
23
24 35 reconstruction. The quality of the studies was evaluated and a meta-analysis of the
25
26
27 36 muscle strength outcomes was conducted on reported data.
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29 37 Results: Fourteen studies were included in this systematic review; eight Randomized
30
31
32 38 Control Studies (RCT) and six non-Randomized Control Studies (non-RCT). A meta-
33
34 39 analysis was performed involving eight of the included studies (4 RCTs & 3 non-
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36
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40 RCTs). At 600/sec and 1800/sec, patients with BPTB graft showed a greater deficit in
38
39 41 extensor muscle strength and lower deficit in flexor muscle strength compared with
40
41 42 patients with HST.
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44 43 Conclusion: This systematic review of Level III evidence showed that isokinetic
45
46 44 muscle strength deficits following ACL reconstruction are associated with the
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49 45 location of the donor site. These deficits appear to be unresolved up to two years after
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51 46 ACL reconstruction.
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54 47
55 48 Keywords: ACL reconstruction, isokinetic muscle strength, systematic review, meta-
56
57 49 analysis.
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60 50 Level of evidence; III
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 51
1
2 52 Introduction
3
4
5 53 Rupture of the Anterior Cruciate Ligament (ACL) is one of the most common
6
7 54 athletic injuries of the knee [17, 60, 14]. Lyman et al recently estimated that the
8
9
10 55 frequency of ACL reconstruction is increasing in the United States and that younger
11
12 56 patients are at a higher risk for re-rupture of the ACL graft [4|]. The consequences of
13
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15 57 an ACL rupture to the function of the involved limb are multifaceted and possibly
16
17 58 include a decrease in joint stability, muscle weakness, meniscal damage, pain and, in
18
19
59 the long term, development of osteoarthritis [61, 30, 72, 66, 54, 29, 46, 51, 58, 47,
20
21
22 60 50]. In an attempt to prevent these deficits in joint function, reconstruction of ACL
23
24 61 has become one of the most common orthopaedic interventions. Although many
25
26
27 62 different surgical techniques and an increasing number of graft types have been
28
29 63 described in the literature, autograft reconstruction using Bone Patellar Tendon Bone
30
31
32 64 (BPTB) or Hamstrings Tendon (HST) appear to be the most popular grafts choices [4,
33
34 65 12, 23, 24, 26, 53, 45].
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36
37
66 Despite, a plethora of recently published comparative studies, the relative
38
39 67 effectiveness of the different grafts used for the reconstruction of ACL remains
40
41 68 unclear [4, 6, 7, 11, 12, 15, 23, 24, 27, 33]. Maximizing knee stability after ACL
42
43
44 69 reconstruction is one of the most important criteria for the choice of graft.
45
46 70 Postoperative stability allows the performance of rehabilitation protocols that aimed
47
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49 71 to restore normal function and thus safe and fast return to pre-injury activity level
50
51 72 [48]. The superior post-operative stability afforded by BPTB autograft is likely to be
52
53
54 73 related to enhanced healing from bone-to-bone attachments [3, 59, 71]. However,
55
56 74 increased donor- site morbidity has been reported after harvesting BPTB autograft.
57
58
75 Specifically, anterior knee pain, quadriceps weakness and worse results in functional
59
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64 3
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 76 tests along with an increased rate of patellar fractures have been observed [43, 44, 40,
1
2 77 27, 49]. Harvesting of the HST autograft may avoid some of these post-operative
3
4
5 78 problems, but is associated with hamstring muscle weakness and slower healing of the
6
7 79 graft attachment site that may predispose patients to higher risk of re-rupture [69, 2,
8
9
10 80 65]. Thus, both of these graft choices are limited in the their ability to restore knee
11
12 81 function for people with ACL rupture, and there is consequently an ongoing debate
13
14
15 82 concerning the superiority of one graft over the other. An imporant aspect of this
16
17 83 debate is the outcome of lower limb muscle strength following either of these graft
18
19
84 types.
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21
22 85 Evaluation of muscle stength can be accomplished by using functional tools
23
24 86 (incorporating hop or twisting) or single joint evaluation tools [52, 9, 2]. One of the
25
26
27 87 most commonly used tools that is reliable in assessing single-joint muscle strength is
28
29 88 isokinetic dynamometry [56, 19]. In comparison to other measures of strength,
30
31
32 89 isokinetic dynamometry allows quantification of muscle strength deficit through the
33
34 90 assesement of specific parameters like work per unit, torque at spefici joint angles and
35
36
37
91 the widely used peak torque value [56, 19, 66, 22]. In the majority of studies, that
38
39 92 investigate muscle strength following ACL recontruction, the strength of the operated
40
41 93 limb is recorded as a deficit or gain in comparison to the contralateral healthy limb.
42
43
44 94 Restoration of similar muscle strength between reconstructed and healthy
45
46 95 knee, is considered to be a critical factor for a safely return back to dynamic activities
47
48
49 96 [48]. Thus, the restoration of muscle strength ratio between the operated and
50
51 97 contralateral limbs for both the quadriceps and the hamstrings is crucial αfter an ACL
52
53
54 98 reconstruction for a fast an uneventful return to pre-injury activities [48]. There is
55
56 99 evidence that muscular recovery is closely related to pre-operative muscle strength the
57
58
100 time between injury and reconstruction and the pre and post surgery rehabilitation [22,
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64 4
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 101 55, 8]. In addition, changes in the sensory system with ACL reconstruction, such as
1
2 102 alterations in the somatosensory evoked potentials or the development of inconsistent
3
4
5 103 postural synergies, may also influence muscle [18].
6
7 104 Although many authors have compared lower limb muscle strength in patients
8
9
10 105 with ACL reconstruction after either BPTB or HST grafts, the plethora of information
11
12 106 is difficult to interpret. Therefore, a systematic review of the literature is warranted to
13
14
15 107 synthesize reported findings of the isokinetic muscle strength in studies comparing
16
17 108 ACL reconstruction using either BPTB or HST autografts. Clarification of muscle
18
19
109 strength recovery after ACL reconstruction using either graft type will enhance
20
21
22 110 decision-making with regards to graft choice and rehabilitation.
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24 111
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 112
1
2 113 Material and methods
3
4
5 114
6
7 115 A thorough search of the databases MEDLINE, Cinahal and EMBASE for
8
9
10 116 articles that compared muscle strength using isokinetic dynamometry between
11
12 117 patients that had undergone ACL reconstruction with either BPTB or HST autograft
13
14
15 118 was completed in September 2009. Full text articles published in English were
16
17 119 searched using variations and combinations of the following terms: anterior cruciate
18
19
120 ligament reconstruction, knee reconstruction, dynamometry, strength, weakness, and
20
21
22 121 torque.
23
24 122 To be included in this review, articles must have:
25
26
27 123  compared two groups of patients that had undergone ACL reconstruction - one
28
29 124 of the groups must have received BPTB autograft and one HST autograft
30
31
32 125  evaluated knee flexor and extensor isokinetic muscle strength between 4 and
33
34 126 24 months after ACL reconstruction surgery
35
36
37 127  been published in English language.
38
39 128 The following criteria were used to exclude articles from the systematic review
40
41
42 129 Studies were not included if:
43
44 130
45
46
47 131  studies did not include original data.
48
49 132  any participants had undergone revision of ACL
50
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52 133  participants had undergone multiple-ligament reconstruction.
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54 134
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135 Studies of different methodological design were included in this systematic
58
59 136 review and are subject to different biases. Therefore, multiple tools were used to
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 137 assess the quality of included studies. Randomized Control Trials (RCT) were
1
2 138 assessed for quality using the PEDRO scale [20] which assesses the quality of studies
3
4
5 139 based on 11 criteria. All other study designs were assessed using the tool described
6
7 140 by Downs and Black [21]. The assessment of methodological quality was completed
8
9
10 141 by 2 reviewers independently. Disagreement was resolved by discussion with a 3rd
11
12 142 reviewer.
13
14
15 143
16
17 144 Extraction of Data
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19
145
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22 146 Two independent reviewers read all of the articles in the final yield and
23
24 147 systematically extracted pre-defined relevant data. Demographic details of
25
26
27 148 participants were extracted from all articles in addition to the descriptive variables of
28
29 149 isokinetic strength assessment at all speeds.
30
31
32 150 A meta-analysis was conducted on the findings of isokinetic evaluations at
33
34 151 testing speeds of 600/sec and 1800/sec an average of 12 months after ACL
35
36
37
152 reconstruction surgery. To be included in the meta-analysis, the mean and measures of
38
39 153 variability must have been reported. Wherever the outcomes were not presented in a
40
41 154 form suitable for direct inclusion in the meta-analysis, the corresponding authors were
42
43
44 155 contacted by email in an attempt to obtain the data required for meta-analysis
45
46 156 (numbers of participants, mean scores and SDs).
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49 157
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51 158 Statistical Analysis
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54 159 Muscle strength of the operated limb was extracted when reported either as a
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56 160 percentage of the uninvolved limb (i.e Limb Symetry Index), or as a percentage
57
58
161 deficit of the uninvolved limb (100 X deficit of injured leg/deficit of uninjured leg).
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64 7
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 162 Mean differences and 95% confidence intervals were calculated from the extracted
1
2 163 data. Random-effects models was used to pool data. Review Manager 5 (Version:
3
4
5 164 5.0.24) software was used for the calculation of effect sizes.
6
7 165
8
9
10 166 Results
11
12 167 A total of 1532 published studies were identified in the original search of
13
14
15 168 databases. Following the application of inclusion and exclusion criteria a final yield of
16
17 169 14 studies were included in this systematic review as presented in the flow chart
18
19
170 (Appendix 1). Of the 14 included studies eight were RCT, and six non Randomized
20
21
22 171 Control Trials – (non-RCT).
23
24
25 172 The study design and the characteristics of each study included in this review
26
27
28 173 are presented in Table 1.
29
30 174 Quality assessment of the RCTs and the non- RCTs are presented in table 2
31
32
33 175 and 3. Inadequate randomization may allow the introduction of bias, however only 3
34
35 176 of the 8 RCTs reported the process of patient randomization. Although blinding of
36
37
38 177 the patient and surgeon is not always possible in this field of research, only 2 studies
39
40 178 reported that assessors were blinded to the group allocation of patients.
41
42
179
43
44
45 180 Muscle strength outcomes
46
47 181 The muscle strength outcomes that were reported from all studies are
48
49
50 182 presented in Tables 4 (for RCTs) and 5 (for non-RCTs).
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52 183 Six studies [5, 11, 12, 7, 16, 68] found no significant difference between
53
54
55 184 BPTB and HST for isokinetic muscle strength for knee extensors or knee flexors at
56
57 185 follow up times between 4 and 24 months after reconstruction.
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64 8
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 186 Four studies [26, 10, 42, 35] found significant extensor muscle strength deficit
1
2 187 in the operated limb in the BPTB group compared to the HST group at different
3
4
5 188 follow up times between 4 and 24 months. In addition six studies [10, 26, 42, 31, 70,
6
7 189 13] found significant deficits of the flexor muscles in the operated limb in HST group
8
9
10 190 compared to the BPTB group at different follow-up times between 4 and 24 months.
11
12 191 Sufficient data were provided in only four of the RCTs [11, 16, 26, 42] and
13
14
15 192 three of the non-RCTs [13, 68, 70] to conduct a meta-analysis on findings 12 months
16
17 193 after ACLR.
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19
194 Figures 1 and 2 show forest plots that summarize quadriceps and hamstring
20
21
22 195 strength for patients at a speed of 60°/sec. There were 3 articles where muscle
23
24 196 strength of the operated limb was reported as a percentage of the uninvolved limb.
25
26
27 197 For patients with HST graft, quadriceps strength was an average of 9% stronger and
28
29 198 hamstrings strength was 8% weaker than patients with BPTB graft. Two articles
30
31
32 199 reported muscle strength of the operated limb as percentage deficit of the uninvolved
33
34 200 limb. Similarly, patients with HST graft showed a 3% lower deficit in quadriceps
35
36
37
201 strength and 9% greater deficit in hamstrings strength than patients with BPTB.
38
39 202 Figures 3 and 4 show forest plots that summarize quadriceps and hamstring
40
41 203 strength for patients at a speed of 180°/sec. There were 2 articles where muscle
42
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44 204 strength of the operated limb was reported as a percentage of the uninvolved limb.
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46 205 For patients with HST graft, quadriceps strength was an average of 7% stronger and
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48
49 206 hamstrings strength was 9% weaker than patients with BPTB graft. Two articles
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51 207 reported muscle strength of the operated limb as percentage deficit of the uninvolved
52
53
54 208 limb. Similarly, patients with HST graft showed a 1% lower deficit in quadriceps
55
56 209 strength and 20% greater deficit in hamstrings strength than patients with BPTB.
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58
210
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 211 Discussion
1
2 212 The most important finding of the present study was the apparent trend for
3
4
5 213 muscle weakness that is specific to the graft donor site following ACL reconstruction.
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7 214 The meta-analysis performed showed that extensor muscle strength deficit exists in
8
9
10 215 ACL reconstructed knees using BPTB autograft and that flexor muscle strength deficit
11
12 216 exists in ACL reconstructed knees using HST autografts, 12 months post operatively.
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14
15 217 Not all studies reported muscle weakness in one group of patients or the other.
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17 218 Six studies [5, 11, 12, 7, 16, 68] did not find significant differences in extensor or
18
19
219 flexor muscle strength between BPTB or HST group, at any testing speed (60°/sec,
20
21
22 220 120°/sec, 180°/sec, 240°/sec, 300°/sec). In contrast, eight studies found differences
23
24 221 between groups. Significant quadriceps muscle strength deficit in BPTB group was
25
26
27 222 observed in four studies [10, 42, 26, 35] and six studies found significant hamstrings
28
29 223 muscle deficits in HST group [10, 42, 26, 13, 31, 70]. All of the studies evaluated
30
31
32 224 patients between 4 and 24 months after surgery and muscle weakness was found to
33
34 225 persist throughout this period. These findings are in agreement with other reviews [57,
35
36
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226 19], that have concluded that the graft site affects muscle strength.
38
39 227 There is an obvious trend for quadriceps deficit at BPTB group compared to
40
41 228 HST group and a trend for hamstrings deficit in HST group compared to BPTB group
42
43
44 229 at 12 months post-operative. The results of the meta-analysis showed that difference
45
46 230 between BPTB and HST group for extensor muscle strength was nearly 10% at the
47
48
49 231 speed of 600/sec and 1800/sec and that for flexor muscle strength was 20% at
50
51 232 1800/sec. It is clinically accepted that anything less than a 10% difference between
52
53
54 233 limbs is considered inconsequential [39]. Although the difference in quadriceps
55
56 234 strength between sides was not greater than 10%, the difference in hamstring strength
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235 exceeded this clinical limt. It is difficult to know what the implications for this
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64 10
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 236 asymmetry between limbs are, given that most research has focused on investigating
1
2 237 asymmetrical quadriceps weakness. Further research is therefore needed to establish
3
4
5 238 whether such a large hamstring weakness in the operated limb of patients with HST
6
7 239 graft has any clinical relevance.
8
9
10 240 The apparent trend for muscle strength weakness related to the donor site may
11
12 241 be explained by previous research. It seems that harvesting the patellar tendon
13
14
15 242 autograft during the ACL reconstruction may alter the length-tension relationship of
16
17 243 the extensor mechanism [32] and consequently contribute to extensor muscle strength
18
19
244 deficit. It is also described that muscle function might be altered due to the attenuation
20
21
22 245 of the gamma loop function caused by the initial ACL injury and that is not restored
23
24 246 after the ACL reconstruction. The mechanoreceptors located within the ACL play an
25
26
27 247 important role in enhancing the activity of gamma motor neurons (contributing, to a
28
29 248 normal muscle function) [36, 62, 38], however this mechanism is not restored with
30
31
32 249 ACL reconstruction, and may therefore also play a role in the extensor muscle
33
34 250 weakness seen after harvesting the BPTB graft. Furthermore, knee pain and effusion
35
36
37
251 have been documented up to 12 months following ACL reconstruction and could alter
38
39 252 the neural control of the quadriceps [64, 37, 67].
40
41 253 Strength deficits in the knee flexor muscles may be more easily explained.
42
43
44 254 There is evidence that tendon fibers can regenerate following harvesting of the
45
46 255 hamstring tendon to become similar to healthy and non harvested fibers [25, 28].
47
48
49 256 However, Hioki et al [34] found an atrophy of hamstrings’ muscle fibers as well as
50
51 257 hypertrophy of the semimembranosus and biceps muscles, after harvesting the
52
53
54 258 hamstrings tendon. Moreover, they demonstrated that after harvesting the hamstrings
55
56 259 tendon the semitendinosus muscle assumes different shapes and movements and that
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64 11
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 260 each pattern was related to different knee flexor strength. It is not clear how these
1
2 261 changes in morphology affects muscle and knee function.
3
4
5 262 Regardless of the physiological explanations for muscle weakness, it is clear
6
7 263 that restoration of muscle strength must focus on increasing muscle strength following
8
9
10 264 ACL reconstruction to maximize functional outcomes. In particular, it appears that
11
12 265 patients with different graft types may be susceptible to muscle strength that is
13
14
15 266 specific to graft type. These findings suggest that rehabilitation that addresses muscle
16
17 267 weakness specfic to graft type may enhance strength outcomes after ACL
18
19
268 reconstruction.
20
21
22 269 The findings of muscle weakness related to graft donor site were not
23
24 270 consistent throughout all of the studies included in this review. There were some
25
26
27 271 methodological differences between these studies that may explain this inconsistency.
28
29 272 The method of randomization was not reported or was insufficient for the most of the
30
31
32 273 RCTs. Only three [11, 26, 42] used a specific random allocation, which verifies that
33
34 274 allocation was concealed. This allows for a bias that potentially could alter the
35
36
37
275 findings of these studies. Although almost all RCTs assessed patients with the same
38
39 276 activity level, three did not report the sex of the patients despite the plethora of
40
41 277 information that gender influences outcome after ACL reconstruction. Therefore, the
42
43
44 278 generalizability of the findings reported in these studies may be limited [1, 63].
45
46 279 Although blinding is one of the most important factors to limit bias in a RCT, no
47
48
49 280 patients or therapist and only 2 studies reported that assessors were blinded to patient
50
51 281 group allocation. Only in the trials of Aglietti et al [5] and Maletis et al [42] the
52
53
54 282 assessors were blinded. Again, the potential for bias in the findings of those studies
55
56 283 that did not blind assessors needs to be considered. The studies that were not RCTs
57
58
284 were subjected to different biases. Because patients in these studies were not
59
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61
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64 12
65
 285 randomized to receive either a BPTB or HST graft, it is important that both groups be
1
2 286 similar at baseline on factors that may confound muscle strength findings. However,
3
4
5 287 3 studies did not adequately describe that groups were similar on important
6
7 288 demographic characteristics such as height and weight. These limitations need to be
8
9
10 289 considered when interpreting the findings of this review. Future work that compares
11
12 290 the muscle strength outcomes between patients with either BPTB and HST ACL
13
14
15 291 reconstruction need to consider these factors when designing future research.
16
17 292 There are some limitations that need to be considered when interreting the
18
19
293 findings of this review. The meta-analysis was limited to only half of the studies
20
21
22 294 included in the review because of disparity in the parameters of isokientic testing (for
23
24 295 example, the speed of testing, and the time since surgery). Nevertheless, studies that
25
26
27 296 did not evaluate muscle strength according to the strict criteria were still included in
28
29 297 the systematic review and contribute significantly to the information that details
30
31
32 298 recovery of muscle strength following ACL reconstruction.
33
34 299
35
36
37
300 Conclusions
38
39 301 Although not all studies reported muscle strength differences between patients
40
41 302 with either BPTB or HST graft ACL reconstruction, there was an obvious trend
42
43
44 303 towards greater muscle weakness that was dependent on the graft donor site.
45
46 304 Rehabilitation that is specific to this difference in muscle strength between graft types
47
48
49 305 is needed.
50
51 306 Furthermore, more high quality studies need to be conducted assessing the
52
53
54 307 muscle strength recovery after the reconstruction of the torn ACL, in order to reveal a
55
56 308 potential superiority of a graft type over the other graft options.
57
58
309
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64 13
65
 310
1
2 311 Table 1. Characteristics of the included studies. (RCT-> Randomized Control
3
4
5 312 StudyNon RCT -> non, Randomized Control Study, BPTB-> Bone Patella Tendon
6
7 313 Bone, HST-> Hamstring (when is not specified if the graft was semitendinosus or
8
9
10 314 somitndinosus/gracilis), ST -> Semitendinosus, ST/G-> semitendinosus/Gracilis, PT-
11
12 315 > Patella tendon, IKDC International Knee Documentation Committee, KOOS
13
14
15 316 Knee injury and Osteoarthritis Outcome Score, VAS scale Visual Analog Scale,
16
17 317 FL Flexion, EX Extension, ATT Anterior Tibial Translation, ROM Range
18
19
318 Of Motion, *  We communicated with the author about the sex)
20
21
22 319
23
24
ISOKINETIC
25 AUTHOR POST-
STUDY PATIENTS REHAB MUSCLE
26 YEAR OUTCOMES OPERATIVE
DESIGN SEX PROTOCOL STRENGTH
NATION FOLLOW UP
27 OUTCOMES
28 KT-1000
29 IKDC
30 KOOS
120p VAS scale for
31 60BPTB analyzing subjective FL/EX Isokinetic
32 Aglietti 2004 Description of 4, 12 and 24
RCT (46M/14F) knee complaints at 60 °/sec.
the program months
33 60 HAST ROM 120°/sec. 180°/sec
34 (46M/14F) Functional knee score
35 for anterior knee
pain.
36 Radiography
37 45p
38
39
40
Andersson
2002
Non
RCT
22BPTB
23HST
No sex
Shelbourn and
Nitz (1990) - FL/EX Isokinetic
60°/sec concentric
/eccentric
6 and 12 months

mentioned
41 KT-1000
42 VAS scale for patient
43 satisfaction
72P
44 VAS scale for
35BPTB
kneeling problems FL/EX Isokinetic
45 Aune 2001 (19M/16F) Shelbourn and 6, 12, and 24
RCT Cincinnati knee score at 60 °/sec,
46 37HST Nitz (1990) months
system 240°/sec
(21M/16F)
47 Stairs
48 Hopple test
Single-legged hop
49 test
50
KT1000
51 45p
IKDC
52 22BPTB
ATT
Beard 2001 (18M/4F) Shelbourn and FL/EX Isokinetic
53 RCT Lysholm score, 6 and 12 months
23HST Nitz (1990) at 60°/sec
54 Tegner activity score,
(15M/8F)
55 *
56
153p
57 87BPTB FL/EX Isokinetic
58 Bizzini 2006 Non Description of
(54M/ 33F) at180°/sec, 11 months
RCT the program KT 1000
59 66HST 300°/sec
60 (45M/21F)
61
62
63
64 14
65
 KT 1000, Pivot Shift,
52p
1 IKDC FL/EX Isokinetic
Beynnon 26BPTB
2 Description of ROM at 60°/sec 2,4,6,12 and 36
2002 RCT (18M/10M)
the program Tegner, 180°/sec, 240°/sec months
3 26HST
One-leg-hop,
4 (13M/15F)
duckwalking, squat.
5 l06p
6 38 PT,
7
8
9
Carter 1999
RCT
33 ST
35 ST/G
No sex
Description of
the program - FL/EX Isokinetic
at 180°/sec,
300°/sec
6 months

mentioned
10
11
65p KT-1000, Lachmann
12 34BPTB IKDC FL/EX Isokinetic
13 Feller 2003 Shelbourn and 4, 8, and 12
RCT (8F/23M) Cincinnati at
Nitz (1990) months
14 31HST Scores 60°/sec, 240°/sec
15 (10F/24M) Anterior knee pain

16
CA 4000
17 IKDC
18 80p
Tegner scale
40BPTB FL/EX Isokinetic
19 Gobbi 2003 Non Description of Noyes scale 3, 6, 12 and 36
40HST at 60°/sec,
20 RCT the program Lysholm months
No sex 180°/sec, 300°/sec
VAS scale for pain
21 mentioned
ROM
22
23
24 CA 4000
25 IKDC
99p Lachman and pivot
26 BPTB 51 shift FL/EX Isokinetic
27 Jansson 2003 Description of
RCT HST 48 Lysholm knee score at 60°/sec, 12 and 24 months
the program
28 No sex Tegner activity level 180°/sec
29 mentioned Kujala patellofemoral
score
30 MRI
31
32 FL/EX Isokinetic
Kt1000 IKDC at 60°/sec 180°/sec
33 99p Lysholm ,300°/sec
34 46BPTB Tegner ABD/ADD
Maletis 2007 Description of 6,12 and 24
35 RCT (31M/15F)
the program
Physical examination 60°/sec 180°/sec
months
36 53 HAST ROM 300°/sec
(45M/8F) Single hop test INT/EXT rot
37 Short form SF 36 60°/sec 180°/sec
38 300°/sec
39
68p
40 34HST
KT 1000
FL/EX Isokinetic
41 Two 2005 Non Description of IKDC 3, 6, and 24
34BPTB at 60°/sec
RCT the program months
42 No sex 240°/sec
43 specified
44 34p IKDC
45 17BPTB KT 1000
46 (16M/1F) Kinematic walking
Webster 2005 Non FL/EX Isokinetic BPTB-11 months
17HST Description of up/down
47 RCT
(16M/1F) the program Kinetic walking
at 60°/sec HST-9.3 months
48 17 up/down
49 CONTROL
50 34p17BPTB
ROM
51 Witvrouw (10M/7F) FL/EX Isokinetic
Non KT 1000 6weeks 3,6 and 12
2001 32HST Description of at 60°/sec
52 RCT
(17M/15F) the program
Lysholm, Tegner,
240°/sec
months
53 Kujala scales
54
55
56
57
58
59
60
61
62
63
64 15
65
 1
2
3
4
5
6
7
8 320 Table 2. Results from the methodological assessment of the eight RCTs using the Pedro scale. (Y: Yes
9 321 N: No)
10
11 Item Item Item Item Item Item Item Item Item Item Item
12 Pedro Criteria no.1 no.2 no.3 no.4 no.5 no.6 no.7 no.8 no.9 no.10 no.11
13 Key outcome
14 Eligibility Subjects randomly Measures
Concealed Blinding of Blinding of Blinding of obtained from Intention Appropriate
15 criteria allocated to Baseline data of
allocation subjects therapists assessors > 85% of the to treat statistics
16 specified groups variability
subjects
First author (year)
17
18
19 Agglieti et al 2004 Y N N Y N N Y Y Y Y N
20
21
22
23 Aune et al 2001 Y N N Y N N N Y Y Y N
24
25
26 Beard et al 2001 Y Y Y Y N N N Y Y Y Y
27
28
29
30 Beynnon et al 2002 Y N N Y N N N Y Y Y N
31
32
33 Carter et al 1999 N N N N N N N Y N Y Y
34
35
36
Feller et al 2003 Y Y Y Y N N N Y Y Y Y
37
38
39
40 Jansson et al 2003 Y N N Y N N N Y Y Y N
41
42
43
44
45
46
47
48 16
49
 1
2
3
4
5
6
7
8 Maletis et al 2007 Y Y Y Y N N Y Y Y Y N
9
10 322
11 323
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48 17
49
 1
2
3
4
5
6
7
8 324 Table 3. Results from the methodological assessment of the six non-RCTs using the Downs and Black scale. (Y: Yes
9 325 N: No)
10
11
326
12 Downs & Black Item Item Item Item Item Item Item Item Item Item Item
13 criteria no. no. no. no. no. no. no. no. no. no. no.
14 1 2 3 5 6 7 12 16 18 25 27
15 Findings Measures of Patients Modification
16 Outcomes Patients Confounders Planned Appropriate Power
Clear aim clearly random represent for
described described described analysis statistics calculation
17 described variability population confounders
18
First author (year)
19
20 Anderson 2002 Y Y Y Y Y Y Y X Y X N
21
22
23
24 Bizzini 2006 Y Y Y Y Y Y Y X Y X N
25
26
27 Gobbi 2003 Y Y N N Y N Y X Y X N
28
29
30
31 Tow 2005 Y Y N N Y N Y X N X N
32
33
34 Webster 2005 Y Y Y Y Y Y Y X Y X N
35
36
37
38 Witvrow 2001 Y Y Y Y Y Y N X Y Y N
39
40
41
42
43
44
45
46
47
48 18
49
 327 Table 4. Muscle strength outcomes of the included RCT, at the time between 4-24 months. (ND: no
1
2 328 difference between groups (BPTB vs HST) for flexion/extension strength, - : No evaluated)
3
4
5 RCT Isokinetic-Flexion/Extension
6
7 AUTHO
8 R YEAR
4 months 6 months 8 months 11 months 12 months 24 months
9
10 ND between
ND between groups ND between groups at
11 Aglietti
at 60°/sec, 120°/sec, — — — groups at 60°/sec, 60°/sec,
12 2004
180°/sec 120°/sec, 180°/sec 120°/sec,
13 180°/sec
14 Extension deficit
Flexion deficit Flexion
15 in BPTB group at
in HST group at deficit in
16 Aune 60°/sec, 240°/sec
— — — 60°/sec 240°/sec HST group
2001 Flexion deficit in
17 at 60°/sec
HST group at
18 240°/sec
240°/sec
19
20 Beard ND between groups ND between
— — — —
21 2001 at 60°/sec groups at 60°/sec
22
23 ND between
Beynnon
— — — — groups at 60°/sec, —
24 2002
180°/sec, 240°/sec
25
26 ND between groups
Carter
— at 180°/sec, — — —
27 1999
300°/sec —
28
29 Extension
Extension deficit in
deficit in BPTB Flexion deficit in
30 Feller BPTB group at
— group at — HST group at —
31 2003 240°/sec
60°/sec, 60°/sec
32 240°/sec
33 ND between
Extension deficit
34 Jansson — groups at
— — — in BPTB group at
2003 60°/sec,
35 60°/sec 180°/sec
36 Extension
37 Extension deficit in
38 Extension deficit
deficit in BPTB BPTB
in BPTB group at
39 group at 60°/sec, group at
Maletis
60°/sec, 180°/se,
40 — — — 180°/se, 300°/sec 60°/sec,
2007 300°/sec Flexion deficit in
41 Flexion deficit in 300°/sec
HST group at Flexion
42 HST group at
180°/sec, deficit in
43 180°/sec
300°/sec HST group
44 at 180°/sec
45
46 329
47
48 330
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64 19
65
 331
1
2 332 Table 5. Muscle strength outcomes of the included non-RCT, at the time between 4-24 months. (ND:
3
4 333 no difference between groups (BPTB vs HST) for flexion/extension strength, - : No evaluated)
5
6
334
7
8
9 NRCT Isokinetic-Flexion/Extension
10
11 AUTHOR
4 months 6 months 8 months 11 months 12 months 24 months
12 YEAR
13
ND between ND between
14 Andersson
— groups at — — groups at —
15 2002
60°/sec 60°/sec
16
17 Flexion deficit
18 Bizzini in HST group
19 — — — —
2006 — at 180°/sec,
20 300°/sec
21
22 Flexion deficit
in HST group
23 Gobbi 2007 — — — — —
at 60°/sec,
24 180°/sec,
25 300°/sec
26 Trend
27 Trend towards towards
Two 2009 — HST flexion — — — HST flexion
28 muscle muscle
29 weakness weakness
30 9.3-11 Months
31 Webster
— — — —
32 2005 ND between groups at 60°/sec,
240°/sec
33
Flexion deficit
34 Flexion deficit
Witvrow — in HST group
35 in HST group — — —
2001 at 60°/sec,
at 60°/sec,
36 240°/sec
37 335
38
39
40 336
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64 20
65
 337 Figure Legents
1
2 338 Figure 1
3
4 339 Forest plots for isokinetic extensor muscle strength at 60°/sec at 12 months.
5
6 340 BPTB: Bone Patellar Tendon Bone, HST: Hamstring, SD: standard deviation, CI: confidence interval
7
8 341 Figure 2
9
10 342 Forest plots for isokinetic flexor muscle strength at 60°/sec at 12 months.
11
12 343 BPTB: Bone Patellar Tendon Bone, HST: Hamstring, SD: standard deviation, CI: confidence interval
13
14
344 Figure 3
15
16
345 Forest plots for isokinetic extensor muscle strength at 180°/sec at 12 months
17
18
19
346 BPTB: Bone Patellar Tendon Bone, HST: Hamstring, SD: standard deviation, CI: confidence interval
20
21
347 Figure 4
22
23
348 Forest plots for isokinetic flexor muscle strength at 180°/sec at 12 months
24
25 349 BPTB: Bone Patellar Tendon Bone, HST: Hamstring, SD: standard deviation, CI: confidence interval
26
27 350
28
29 351
30
31
32 352
33 353
34 354
35 355
36
37
356
38 357
39 358
40 359
41 360
42
43 361
44 362
45 363
46 364
47
48
365
49 366
50 367
51 368
52 369
53
54 370
55 371
56 372
57 373
58
374
59
60
61
62
63
64 21
65
 375 Appendix 1. Flow chart of the search and included and excluded studies.
1 376
2
3 1532 articles without duplicates from dtabases
4 (MEDLINE, Cinahal and EMBASE)
5
6
7 378
8
9 379 1532 titles reviewed
10 380
11 381
12
13
14 645 excluded from title (291 not ACL studies, 125 not in
15
16 English, 201 cadaver/not human studies, 9 revision of ACL, 2
17 total knee arthroplasty, 17 case report studies)
18
19
20
21 383
22
23
384 887 abstract reviewed
24
25 385
26
27
691 excluded from abstract (147 studies used only BPTB
28 graft, 132 studies used only HST graft, 210 studies did not
29 compare muscles strength outcome between BPTB or HST
30 graft, 45 ACL studies without reconstruction, 26 studies
31 tested allografts, 97 review studies, 27 studies tested subject
32
33 after 24 months, 7 studies tested subject before 4 months)
34
35 387
36
37 196 full text reviewed
38 388
39
40 389
41 182 excluded (138 studies did not compare muscles strength
42 outcome between BPTB or HST graft between the time of 4-24
43 390 months, 12 studies used only BPTB graft, 17 studies used only
44 HST graft, 12 studies did not use isokinetic evaluation, 1 study
45 391
46 used cadaver model, 1 did not used isokinetic peak torque value, 1
47 392 study used internal/external muscle strength)
48
49
50
51
52
53
54
14 included in the review
55
56
57
58
59
60
61
62
63
64 22
65
 393 ACKNOWLEDGEMENTS
1
2 394 The authors acknowledge the support from the Greek General Secretariat for Research
3
4 395 and Technology and the European Union (Operative Program Competitiveness;
5 396 AKMON) to the Orthopaedic Sports Medicine Center, and the Hellenic Association
6 397 of Orthopaedic Surgery & Traumatology.
7 398
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64 23
65
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Figure 1
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