Effects Of ACL Reconstruction On In Vivo Quadriceps Contractile Behavior During Weight Acceptance In Walking
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Appropriate knee loading during walking is essential for optimal health of mechanosensitive joint tissues and is largely governed by quadriceps muscle forces. However, individuals with anterior cruciate ligament reconstruction (ACLr) often exhibit quadriceps muscle dysfunction conventionally measured via reduced peak knee extensor moments (pKEM). Recent advances in ultrasound imaging provide a unique opportunity to determine if quadriceps dysfunction also manifests as altered contractile behavior between those with ACLr and uninjured controls. PURPOSE: Determine differences in quadriceps contractile behavior during weight acceptance in walking between ACLr, contralateral, and control limbs. METHODS: Six individuals to date with unilateral ACLr (4 females, 20±2 yrs, BMI: 25.3±1.8, months post-surgery: 7.1±0.7) and 11 uninjured controls (6 females; 24±3 yrs, BMI: 22.0±2.0) walked for 2 min on an instrumented treadmill. We collected motion capture and ground reaction force data and recorded cine B-mode ultrasound images of the vastus lateralis (VL). We quantified pKEM, knee flexion excursion (KFE), and VL fascicle length change during weight acceptance (i.e., heel-strike to the instant of pKEM). We report effect sizes (ES) for all comparisons. RESULTS: pKEM was 25% lower in the ACLr limb (0.18±0.18 Nm/kg) than the contralateral limb (0.24±0.11 Nm/kg, ES=0.40) and 75% lower than for uninjured controls (0.74±0.19 Nm/kg, ES=3.03). Similarly, the ACLr limb exhibited 21% less KFE (11.4±3.4°) than the contralateral limb (14.5±2.2°, ES=1.08) and 32% less KFE than in uninjured controls (16.8±3.5°, ES=1.57). In uninjured controls, VL fascicles shortened by 0.13±0.23 cm during weight acceptance despite 1.21±0.26 cm of muscle-tendon-unit lengthening, alluding to a predominant role of tendon elongation. VL fascicles in the contralateral limb of ACLr subjects also exhibited shortening during weight acceptance (0.07±0.33 cm). Conversely, we observed fundamentally different behavior in the ACLr limb, for which VL fascicles lengthened by 0.10±0.14 cm (vs controls, ES=1.21). CONCLUSION: ACLr alters quadriceps contractile behavior during weight acceptance in walking. Fascicle lengthening unique to the ACLr limb may be a functional consequence of quadriceps dysfunction relevant to altered knee loading.Keywords:
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Delayed treatment of a quadriceps rupture is an infrequent but difficult situation. The fibrous degeneration and muscle retraction and subsequent hiatus present a challenging technical problem. A 54-year-old laborer with a 7-week quadriceps rupture was treated by a method that seems not to have been previously reported. At surgery there was a 9-cm gap that could not be approximated by either a Bunnell suture, or Codvilla lengthening of Scuderi inverted triangle. Repair was successfully accomplished by transposing the inner one-third of the patellar tendon. The tendon was split longitudinally and separated from the medial and lateral aspects in a distal to proximal direction with an osteoperiosteal flap. This was proximally sutured across the gap in the quadriceps mechanism. Eighteen months postoperatively there was no extension lag with knee range of motion of 0 degrees-125 degrees and good power.
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The bone-patellar tendon-bone has been widely used and considered a good graft source. The quadriceps tendon was introduced as a substitute graft source for bone-patellar tendon-bone. We compared the clinical outcomes of anterior cruciate ligament reconstructions using central quadriceps tendon-patellar bone and bone-patellar tendon-bone autografts. We selected 72 patients who underwent unilateral anterior cruciate ligament reconstruction using bone-patellar tendon-bone between 1994 and 2001 and matched for age and gender with 72 patients who underwent anterior cruciate ligament reconstruction using quadriceps tendon-patellar bone. All patients were followed up for more than 2 years. We assessed anterior laxity, knee function using the Lysholm and International Knee Documentation Committee scores, and quadriceps strength, the means of which were similar in the two groups. More patients (28 or 39%) in the bone-patellar tendon-bone group reported anterior knee pain than in the quadriceps tendon-patellar bone group (six patients or 8.3%). Anterior cruciate ligament reconstruction using the central quadriceps tendon-patellar bone graft showed clinical outcomes comparable to those of anterior cruciate ligament reconstruction using the patellar tendon graft, with anterior knee pain being less frequent in the former. Our data suggest the quadriceps tendon can be a good alternative graft choice. Level of Evidence: Level III Therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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An individualized approach to anterior cruciate ligament reconstruction (ACLR) typically includes criteria-based postoperative rehabilitation. However, recent literature has suggested residual quadriceps weakness up to 12 months after ACLR, especially with a quadriceps tendon (QT) autograft.The QT would have poorer quadriceps strength symmetry at 5 to 8 months compared with the hamstring tendon (HS) and patellar tendon (BPTB), but there would be no significant difference at 9 to 15 months among all 3 groups.Cohort study; Level of evidence, 3.Patients who underwent anatomic primary ACLR with an autograft were reviewed retrospectively. Isometric quadriceps and hamstring strength measurements were obtained clinically at 5 to 8 months and 9 to 15 months postoperatively. Return-to-running and return-to-play criteria included greater than 80% and 90% quadriceps strength symmetry, respectively.A total of 73 patients with 5- to 8-month follow-up were identified, and 52 patients had 9- to 15-month data. The QT group had a significantly lower quadriceps index at 5 to 8 months (69.5 ± 17.4) compared with the BPTB (82.8 ± 14.6; P = .014) and the HS (86.0 ± 18.6; P = .001) groups. More patients with an BPTB autograft met criteria for return to running and return to play (60% and 47%, respectively) compared with the QT group (26% and 13%, respectively) at 5 to 8 months. Given the sample sizes available, we observed no significant difference in the quadriceps index and return-to-play and return-to-running criteria at 9 to 15 months among those undergoing ACLR with a QT, BPTB, or HS graft.Patients undergoing ACLR with a QT graft demonstrated clinically meaningful quadriceps asymmetry at 5 to 8 months and 9 to 15 months postoperatively. Additionally, fewer patients in the QT group met criteria for return to play and running at 5 to 8 months than the BPTB and HS groups. These data suggest that a longer time to return to play and specific rehabilitation protocols that emphasize quadriceps strengthening may be necessary because of residual quadriceps weakness after ACLR with a QT graft.
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• Quadriceps contracture in children can result from multiple intramuscular injections. We describe here seven patients with this complication. These patients were unable to completely flex the involved knee. At surgery, extensive fibrosis of the quadriceps muscle was found. Lengthening of the scar and contracted muscle and tendon restored a good deal of flexion. If long-term antibiotic treatment is anticipated, the intravenous route should be employed if possible. (Am J Dis Child131:416-417, 1977)
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Several techniques using different grafts have been described for reconstruction of the patellar tendon after a neglected rupture. Retraction of the quadriceps tendon may compromise repair integrity due to progressive stretching of the graft. The authors present a surgical technique using the central one-third of the quadriceps tendon. This is supported by the fact that the resistance to traction of this segment of the quadriceps tendon equals that of a double-looped semitendinosus graft and that the harvesting of this specific graft promotes muscle inhibition, thus protecting the reconstruction during the recovery period. [ Orthopedics . 2014; 37(8):527–529.]
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Objectives: Graft choice for anterior cruciate ligament (ACL) reconstruction remains controversial. Quadriceps autograft has emerged as an alternative graft choice. However, there remains a paucity of comparative outcomes. Our purpose is to compare subjective outcomes and complications of ACL reconstruction using either BTB or quadriceps autograft. Our hypothesis is that there will be no difference in subjective outcome or complications between groups. Methods: Following IRB approval, retrospective review of prospectively collected data identified consecutive cohorts of patients undergoing ACL reconstruction with either BTB or quadriceps autograft. Surgery was performed by a single sports fellowship trained surgeon between 2011-2019. Patients undergoing concomitant osteotomies, cartilage restoration, and other ligament reconstruction procedures were excluded. Pre- and post-surgical patient reported outcomes (PROs) including IKDC, KOOS, PROMIS, SANE, Tegner, and Marx were compared between groups. Complications requiring re-operation (infection, stiffness, reconstruction failure) were recorded. Results were analyzed statistically. Results: 141 patients met inclusion criteria. There were 72 BTB and 69 quadriceps autografts. Mean age was 20.5 years in the BTB group and 20.7 years in the quadriceps group (p=0.9). 28 of 69 (40.6%) BTB and 34 of 72 (47.2%) quadriceps were female. Pre-operative KOOS Pain (64.5, 78.0, p=0.0007), KOOS QOL (29.6, 37.7, p=0.05), IKDC (44.5, 52.6, p=0.05), and PROMIS Physical Function (39.0, 42.7 p=0.04) scores were significantly higher in the BTB cohort. There were no differences in other baseline PROs. At minimum 6-month follow-up (range 6 - 57 months), patients in both quadriceps and BTB autograft cohorts reported statistically significant improvements in all KOOS domains, Tegner (76.4%, p=0.0002; 94.0%, p=0.000000003), IKDC (67.3%, p=0.0000009; 54.0%, p=0.000000009), SANE (69.4%, p=0.0000001; 70.7%, p=0.000000002), PROMIS Mobility T-Score (30.6%, p=0.0000003; 24.6%, p=0.000002), PROMIS Global Physical Health (15.3%, p=0.00002; 14.3%, p=0.00004), PROMIS Physical Function (33.2%, p=0.0000000008; 29.6%, p=0.00000002), PROMIS Pain Interference (-17.9%, p=0.00000002; -20.8%, p=0.00000000007). Post-operative Tegner (4.7, 6.0, p=0.04) and Global Mental Health (55.7, 60.1, p=0.008) scores were significantly higher in the BTB cohort. Complications were low and not significant between groups. Both quadriceps and BTB autograft cohorts required post-operative re-operations (4.4% and 6.9%, p=0.5). Quadriceps had 2 ligament reconstructions (2.9%) and 1 surgery for stiffness (1.4%). BTB group had 3 ligament reconstructions (4.2%) and 2 surgeries for stiffness (2.8%). Conclusion: Patients undergoing either BTB and quadriceps autograft ACL reconstruction demonstrated significant subjective improvements and low rates of complications requiring re-operation. At mid-term follow-up, the BTB cohort had higher activity and mental health scores.
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