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PURPOSE: Muscle quality is explained by the ratio between muscle size and strength. Conventionally, muscle size is evaluated without considering the composition of contractile and non-contractile tissues in muscle, hence the influence of non-contractile tissues on muscle quality is not fully understood, especially within aging muscle. This study investigated the differences in intramuscular non-contractile tissues between different age and sex groups, and investigated their influence on muscle quality. METHODS: Eighty-two older and 64 young females and males participated. Muscle cross-sectional area (quadriceps and hamstrings), separating contractile and non-contractile areas, was calculated from the magnetic resonance image of the right mid-thigh. Maximal voluntary isometric knee extension and flexion torque was measured. Torque/muscle area and torque/contractile area were calculated for each age and sex group. RESULTS: Non-contractile/muscle area was higher in older than in young individuals in both muscle groups (p < 0.05), and it was greater in the hamstrings than in the quadriceps. For the hamstrings, torque/muscle area was lower in older than in young individuals in both sexes (p < 0.05). However, torque/contractile area did not show the differences between age groups, only between sexes (males>females) (p < 0.05). CONCLUSIONS: The results indicate that 1) the presence of non-contractile tissues varies by age and muscle groups, 2) the extensive presence of non-contractile tissues can contribute to the underestimation of its muscle quality, and 3) the sex differences in muscle quality are influenced by factors other than muscle composition.

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Introduction Forward reaching in sitting has been shown to facilitate muscle contraction in the paretic lower limb of stroke survivors. Change in the sitting surface has been shown to alter the contribution of lower extremity muscles to maintain postural control. This study investigated the effect of forward reaching in a modified sitting position on the paretic lower extremity muscles of patients with stroke. Methods First-time cerebral stroke survivors in their early sub-acute phase were randomly allocated to the experimental or control group. The experimental group engaged in training sessions focusing on reaching a target while seated with only the paretic foot placed on a support, whereas the control group performed the same task with both feet supported on the surface. Each group completed three sets of 10 repetitions of forward reaching for eight days as a part of the training. Quadriceps and tibialis anterior muscle activity in the paretic leg were measured using surface electromyography before the first and after the last session of intervention. Statistical analysis was conducted using parametric tests with a significance level set at p < 0.05. Results Sixty-three subjects completed the study, with 31 in the experimental group and 32 in the control group. The results of the post-intervention analysis indicated a statistically significant increase in the EMG activity of the tibialis anterior and quadriceps muscle surfaces in both groups (p < 0.001). Notably, the experimental group exhibited significantly higher muscle activity in both quadriceps and tibialis anterior compared to the control group (p < 0.001). Conclusion Forward reaching with only the paretic lower limb grounded effectively improves quadriceps and tibialis anterior muscle recruitment in the early sub-acute phase of stroke.

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Background: Patellar dislocation is a knee injury affecting generally young, active individuals, damaging joint ligaments and structures, and impacting sports activity and quality of life. Objective: This review aimed to evaluate the role of the quadriceps femoris muscle in knee extension and to consider whether extensor strength deficits are present in patients who have suffered from a primary or recurrent patellar dislocation and have been treated surgically or conservatively. Methods: This systematic literature review with meta-analysis was performed following the PRISMA Statement criteria. The search engines consulted to select studies were MEDLINE/PubMed, Scopus, and Web of Science/ISI. The JBI Critical Appraisal Checklist tools were applied for the quality assessment based on the specific study design. The outcomes were measurements of the knee extension force of the quadriceps femoris muscle, which were objectively quantifiable with an isokinetic or mobile dynamometer. Results: Of the 891 articles initially identified through the databases, 10 studies with a total of 370 patients were included in the analysis. The results indicated a strength deficit of the quadriceps in patients who had undergone a patellar dislocation, in comparison with the control group, when examining the uninvolved limb or in comparison with the pre-operative values. The overall effect size was large, with a value of -0.99. Conclusions: Our review concluded that after a primary or recurrent patellar dislocation, strength deficits of the quadriceps femoris muscle in the knee extension of the affected limb are frequently observed in surgically or conservatively treated patients. This deficit may persist even after a protracted follow-up of up to three years after injury.

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How to cite this article: Sundarsingh V, Kumar M. Emphasizing Patient-centered Outcomes and Improved Exclusion Criteria in Randomized Controlled Trials for Clinical Nutrition in Critically Ill Patients. Indian J Crit Care Med 2024;28(8):804-805.

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BACKGROUND: Ultrasound may be helpful for muscle mass assessment in heart failure (HF). We aimed to determine the feasibility and prognostic implications of ultrasound-measured quadriceps muscle thickness (QMT) in older patients with HF. METHODS: This was a post-hoc analysis of a multicenter prospective cohort study including patients hospitalized for HF aged ≥ 65 years. QMT at rest and during isometric contractions was measured in the supine position using ultrasound before discharge. RESULTS: The interobserver agreement for measuring QMT was excellent, with intraclass correlation coefficients (ICCs) of 0.979 (95% confidence interval [CI] 0.963-0.988) at rest and 0.997 (95% CI 0.994-0.998) during isometric contraction. The intra-observer reproducibility was also excellent (ICC >0.92). Of the 595 patients (median age: 81 years, 56% male), median QMT at rest and during contraction were 18.9 mm and 24.9 mm, respectively. The patients were grouped according to sex-specific tertiles of height-adjusted QMT. During the median follow-up of 735 days, 157 deaths occurred, and Kaplan-Meier curve analysis showed that the lowest tertile of the height-adjusted QMT was associated with higher mortality. Cox proportional hazard analysis revealed that thinner height-adjusted QMT was independently associated with higher mortality, even after adjusting for conventional risk factors (per 1 mm/m increase: hazard ratio [HR] 0.94, 95% CI 0.89-0.99, P=0.030 [at rest] and HR 0.94, 95% CI 0.90-0.99, P=0.015 [during isometric contraction]). CONCLUSIONS: Ultrasound-measured QMT in older patients with HF is feasible, and thinner height-adjusted QMT at rest and during isometric contraction was independently associated with higher mortality.

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Purpose: Our study aims to evaluate differences in muscle parameters of the quadriceps muscles in patients with knee osteoarthritis (KOA) in older adults. Methods: The study included 40 patients diagnosed with unilateral knee osteoarthritis in the KOA group (KG) and 40 asymptomatic elderly individuals in the control group (CG). Muscle ultrasonic mean echo intensity and shear modulus, as well as tone and stiffness of the rectus femoris (RF), vastus medialis (VM), and vastus lateralis (VL) were analyzed. Additionally, clinical correlations were performed. Results: In the KG group, there were significant differences in echo intensity, shear modulus, and tone between the affected and unaffected sides for RF (p=0.003, 0.019, 0.014), while VM showed significant differences in shear modulus and tone (p=0.006, 0.002). Additionally, VL exhibited significant differences in echo intensity, shear modulus, and stiffness (p=0.007, 0.006, 0.010). Compared to the CG group, the KG group showed significant differences in echo intensity of the affected side RF (p=0.001). VM exhibited statistically significant differences in echo intensity and shear modulus (p < 0.001, p=0.008), while VL showed statistically significant differences in echo intensity, tone, and stiffness (p < 0.001, p=0.028, p < 0.001). The correlation results showed that patients with unilateral KOA, VM, and VL echo intensity were correlated with K-L grade (r = 0.443, p=0.004; r = 0.469, p=0.002). The tone of VL was correlated with VAS and WOMAC (r = 0.327, p=0.039; r = 0.344, p=0.030). Conclusion: The parameters of the quadriceps femoris muscle exhibit asymmetry between the affected and unaffected sides in patients with unilateral KOA, as well as a difference between the dominant side of healthy older individuals and the affected side of KOA.

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SUMMARY: The objective was measure quadricep strength after Total Hip Arthroplasty (THA) and kinetic treatment and then determine its impact on the functional recovery of patients with hip osteoarthritis. A total of 79 (25 were male and 54 were female) patients with THA. Exclusion criteria were previous extra-system kinetic treatment, operated on for hip fracture, not completing the treatment. Maximum Isometric Strength (MIS), Time Up and Go (TUG), Modified Harris Hip Score. There was a significant increase in the MIS of the post-treatment operated knee extension in both men and women (p < 0.0001 SE = 0.43; p < 0.0001 SE = 1.22, respectively). In the TUG, the execution time was significantly lower post-treatment in both men and women (p < 0.0001 SE = 0.77; p < 0.0001 SE = 0.94, respectively). The final Harris score increased significantly post-treatment in male and female (p < 0.0001 SE = 2.90; p < 0.0001 SE = 1.96, respectively). the association between MIS and the Harris score, it was noted that, for a 1 kg increase in this measure compared to the initial assessment, the Harris score, after 12 weeks of treatment, increased by 0.179 points (β = 0.179; p = 0.050). The conclusions were Indicate an increase in knee extension MIS of the operated hip after treatment in both sexes. At the same time, functionality increased post-treatment in both male and female.

El objetivo del estudio fue medir la fuerza del músculo cuádriceps femoral después de la artroplastia total de cadera (THA, por sus siglas en inglés) y el tratamiento kinésico, para determinar su impacto en la recuperación funcional de pacientes con osteoartritis de cadera. En el estudio participaron 79 pacientes con THA (25 hombres y 54 mujeres). Se excluyeron quienes tuvieron tratamiento Kinésico previo fuera del hospital, operación por fractura de cadera y no completar el tratamiento. Las principales medidas tomadas fueron: Fuerza Máxima Isométrica (MIS), Time UP and GO (TUG), Puntuación Modificada de Harris de Cadera. Hubo un aumento significativo en la MIS de la extensión de rodilla del lado operado después del tratamiento tanto en hombres (p<0,0001, EE=0,43) como en mujeres (p<0,0001, EE=1,22). En el TUG, el tiempo de ejecución fue significativamente menor después del tratamiento en hombres (p<0,0001, EE=0,77) y mujeres (p<0,0001, EE=0,94). La puntuación final de Harris aumentó significativamente después del tratamiento en hombres (p<0,0001, EE=2,90) y mujeres (p<0,0001, EE=1,96). En cuanto a la asociación entre MIS y la puntuación de Harris, se observó que por cada aumento de 1 kg en esta medida en comparación con la evaluación inicial, la puntuación de Harris aumentó en 0,179 puntos después de 12 semanas de tratamiento (β=0,179; p=0,050). En conclusión se observó un aumento en la MIS de la extensión de rodilla del lado operado después del tratamiento en ambos sexos. Al mismo tiempo, la funcionalidad aumentó después del tratamiento tanto en hombres como en mujeres.

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Background: Despite increasing use of quadriceps tendon (QT) autograft in anterior cruciate ligament (ACL) reconstruction (ACLR), limited data exist regarding its outcomes in high-risk adolescent athletes. Purpose: To (1) report the outcomes after QT ACLR in adolescent athletes and (2) identify patient-related and surgery-related factors that may influence failure rates after QT ACLR. Study Design: Case series; Level of evidence, 4. Methods: All patients aged 14 to 17 years who underwent primary anatomic, transphyseal, single-bundle QT ACLR between 2010 and 2021 with a minimum 2-year follow-up were included for analysis. Demographic and surgical data as well as preoperative International Knee Documentation Committee (IKDC) and Marx activity scores were collected retrospectively. All patients were also contacted to assess postoperative patient-reported outcomes (PROs), including IKDC and Marx activity scores, and return-to-sports (RTS) data. Outcomes of interest included rates of revision ACLR and ipsilateral complications, contralateral ACL tears, difference in pre- and postoperative PROs, and rates of RTS. Patient and surgical characteristics were compared between groups who required revision ACLR versus those who did not. Results: A total of 162 patients met inclusion criteria, of which 89 adolescent athletes (mean age 16.2 ± 1.1 years, 64% female) were included for analysis at mean follow-up of 4.0 years. Postoperative IKDC scores were significantly higher than preoperative scores (88.5 vs 37.5; P < .001), whereas Marx activity scores decreased postoperatively (14.3 vs 12.2; P = .011). Successful RTS occurred in 80% of patients at a mean time of 9.7 ± 6.9 months, and 85% of these patients returned to the same or higher level of sports. The most common reasons for failure to RTS included lack of time (n = 7, 70%) and fearing reinjury in the operative knee (n = 5, 50%). The overall revision ACLR rate was 10% (n = 9), and contralateral ACL tears occurred in 14% (n = 12) of patients. The overall ipsilateral knee reoperation rate was 22.5% (n = 20). No statistically significant differences in patient or surgical characteristics were observed between patients who underwent revision ACLR and those who did not. Conclusion: At a minimum 2-year follow-up after QT ACLR, adolescent athletes experienced significantly improved postoperative IKDC scores, high rates of RTS, and low rates of graft failure, despite a relatively high ipsilateral reoperation rate. Surgeons may utilize this information when identifying the optimal graft choice for adolescent athletes who have sustained an ACL injury and wish to return to high level of sporting activities.

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Introduction: Patellar instability and dislocation pose complex clinical and surgical challenges, especially in children. Congenital (fixed) and obligatory (habitual) dislocations present significant anatomical and etiological complexity, frequently leading to deformities and functional impairments, which can range from walking difficulties to sports limitations. Conservative treatment is often inadequate. Technique: We describe a surgical technique for treating congenital or obligatory patellar dislocations in patients with various underlying diagnoses-including Down syndrome, nail-patella syndrome, and skeletal dysplasia-that involves extensive subperiosteal quadriceps realignment, distal realignment (Roux-Goldthwait or tibial tuberosity transfer), and optional medial plication. This modified 4-in-1 technique follows the principles described in 1976 by Stanisavljevic, which involves subperiosteal quadriceps mobilization, thus minimizing muscle damage, bleeding, and postoperative muscular adherences. Results: In 24 patients treated at our institution between 2002 and 2021 (35 knees; age range = 5.5-16.8 years; 13 girls, 11 boys), with a mean follow-up of 8.2 years (2.4-20 years), we achieved satisfactory improvements in patellar stability, range of motion, and quality of life with a modified 4-in-1 Stanisavljevic technique. A total of 9 patients (7 with obligatory dislocations and 2 with congenital dislocations) could engage in recreational or competitive sports. The average postoperative pediatric International Knee Documentation Committee (pedi-IKDC) score was 78.45 ± 22.3 (range = 0-100); a patient with DiGeorge syndrome and 1 with multiple epiphyseal dysplasia had scores of 35 and 48, respectively. Discussion: We found at our institution that a modified 4-in-1 Stanisavljevic technique produced favorable outcomes in patellar stability, range of motion, and quality of life in pediatric patients with congenital or obligatory patellar dislocation. More study is warranted to determine the procedure's overall benefits for children with obligatory or congenital dislocations of complex etiology.

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BACKGROUND: Tourniquet is applied in Total Knee Arthroplasty (TKA) to reduce intraoperative blood loss and improve view of surgical field. However, tourniquet use in TKA is still in dispute. Some researchers find that tourniquet may lead to extra side effects such as aggravated pain and limb swelling, while others consider that tourniquet has no significant adverse impact on clinical outcomes of TKA patients. This trial is conducted to evaluate tourniquet effect on TKA patients. METHODS: A prospective, single-blind, randomized controlled trail is adopted with a sample size of 130 knees from August 2020 to February 2023. Patients undergoing TKA are randomly allocated to tourniquet group and non-tourniquet group. Outcomes including quadriceps thickness and stiffness, operation time, total blood loss, intraoperative blood loss, postoperative blood loss, transfusion rate, thigh circumference, knee and thigh VAS, D-Dimer and CRP level, knee function score, patient satisfaction, and complications are evaluated in this trial. Student's t-test, Mann-Whitney U test, Pearson's chi-square test, and Fisher's exact test are used in this study. RESULTS: No significant difference in demographic information and baseline outcomes were found (p > 0.05). Participants in the tourniquet group had significantly less total blood loss and intraoperative blood loss, more postoperative blood loss, and higher D-Dimer level on postoperative day 3 when compared with non-tourniquet group (p < 0.05). Other outcomes including quadriceps thickness and stiffness, operation time, postoperative blood loss, transfusion rate, thigh circumference, knee and thigh VAS, D-Dimer level on postoperative day 1, CRP level, knee function score, patient satisfaction, and complications showed no significant difference (p > 0.05). CONCLUSION: Tourniquet application can effectively reduce intraoperative blood loss and total blood loss, without significant side effects. Hence, we advocate the regular use of tourniquet in primary TKA.

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OBJECTIVE: Lengthening of the quadriceps tendon for dehiscence in chronic rupture. INDICATIONS: Chronic rupture of the quadriceps tendon with delayed diagnosis or failure of primary refixation with a dehiscence between 1 and 5 cm. CONTRAINDICATIONS: Dehiscence of more than 5 cm. SURGICAL TECHNIQUE: Reopen the old incision and lengthen it to about 20-25 cm if necessary. Visualize the rupture. Debridement of the tendon and the insertion. Measurement of the dehiscence. Creation of a V-flap and reinforcement with a holding seam. Gradual mobilization of the V­flap distally and reinforcement with two strong suture cords (braided suture size 5). Drilling of three obliquely ascending drill holes through the patella. Transosseous threading of the two reinforcement cords through the three drill holes. Knotting the reinforcement cords on the patella. Closure of the gap between the patella and the superficial tendon leaflet with a #2 braided suture. Closure of the gap between the V­flap and the quadriceps tendon. POSTOPERATIVE MANAGEMENT: Six weeks of partial weight-bearing with 20 kg in a straight orthosis. Mobility: weeks 1-4 E/F 0-0-60, weeks 5 and 6 E/F 0-0-90. RESULTS: We were able to follow-up 8 patients (mean age: 63.1 ± 4.5 years), who underwent this surgery in the manner described. All patients were able to perform an active extension postoperatively. The Lysholm score increased from 46.4 (±â€¯5.4) points preoperatively to 81.6 (±â€¯6.5) points postoperatively. No further rupture was detectable in the ultrasound examination at latest follow-up after an average of 27 (18-36) months.

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INTRODUCTION: Anterior cruciate ligament (ACL) injuries are common, particularly among athletes, and often result in knee instability and decreased functionality. Arthroscopic ACL reconstruction is the standard treatment, typically using a patellar tendon bone graft (PTBG) or hamstring tendon graft (HTG). The central quadriceps tendon graft (QTG) has been proposed as a superior alternative due to its structural properties. METHODOLOGY: This study involved patients undergoing ACL reconstruction using the central quadriceps tendon graft. Functional outcomes were assessed using the Tegner Lysholm knee score were assessed at preoperative and postoperative intervals of two weeks, three months, and six months. Statistical analysis compared these scores over time. RESULTS: Among the subjects, 90.6% were male and 9.4% were female. Injuries primarily resulted from sports activities and road traffic accidents (46.9% each). Right-side injuries were more prevalent (65.6%). The mean time from injury to surgery was 9.37 months. The mean graft size was 8.75 mm, and the mean tourniquet time was 105.94 minutes. Preoperative tests showed positive results for anterior drawer, Lachman, and pivot shift tests in most patients, which were negative postoperatively. Significant improvements in knee flexion and Lysholm knee scores were observed. Preoperative knee flexion ranged from 0-100° to 0-120°, improving to 0-120° to 0-130° six months postoperatively. The mean Lysholm knee score improved from 47.06 preoperatively to 93.16 at six months. Excellent outcomes were seen in 78.1% of the patients, with 21.9% achieving good outcomes. CONCLUSION: The central quadriceps tendon graft is an effective option for ACL reconstruction, offering excellent functional outcomes and low complication rates. It shows promise as a better alternative to traditional graft types, although further research is necessary to confirm these findings.

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BACKGROUND & AIMS: Body weight is one of the essential indicators of nutritional status, and body weight management is vital in nutritional care. In addition, low body mass index (BMI) was included as a phenotypic criterion in the Global Leadership Initiative on Malnutrition (GLIM) criteria. Furthermore, low BMI has been used in grading the severity of malnutrition (moderate or severe malnutrition) in the GLIM criteria. A recent cross-sectional study reported that muscle mass of the quadriceps in older inpatients with severely low BMI is less than those of older inpatients with moderately low BMI and non-low BMI. However, the longitudinal relationship between body weight and muscle mass of the quadriceps in older inpatients in each BMI category according to the GLIM criteria remains unclear. This study aimed to examine the longitudinal relationship between body weight and muscle mass of the quadriceps in older inpatients in each BMI category according to the GLIM criteria. METHODS: This retrospective cohort study included 179 older inpatients (aged ≥ 70 years) (median [IQR] age: 84.0 [79.0-89.0]). The period of this study was between January 2017 and March 2020. In accordance with the cut-off value of a low BMI for patients aged ≥ 70 years in the Asian population according to the GLIM criteria, the participants were divided into the following three groups: the severely low BMI group (< 17.8 kg/m2) (n = 47), moderately low BMI group (≥ 17.8 to < 20.0 kg/m2) (n = 38), and non-low BMI group (≥ 20.0 kg/m2) (n = 94). The medians (IQR) of the length of hospital stay of the severely low BMI, moderately low BMI, and non-low BMI groups were 71.0 (49.0-98.0) days, 71.0 (50.0-98.0) days, and 50.5 (36.5-103.0) days, respectively. The primary outcome was a change in muscle mass of the quadriceps. The muscle mass of the quadriceps was examined using ultrasound images (i.e., quadriceps thickness). The changes in quadriceps thickness and body weight were calculated by subtracting the quadriceps thickness and body weight at admission from those values at discharge. Multiple linear regression analysis adjusting for confounding factors was used to determine whether the change in body weight was independently and significantly related to the change in quadriceps thickness in the severely low BMI, moderately low BMI, and non-low BMI groups. RESULTS: The means (SD) of the change in quadriceps thickness of the severely low BMI group, moderately low BMI group, and non-low BMI group were 0.0 ± 0.3 cm, 0.1 ± 0.3 cm, and 0.1 ± 0.5 cm, respectively. The means of the change in body weight in those groups were 0.4 ± 2.8 kg, - 1.1 ± 2.7 kg, and - 1.3 ± 4.3 kg, respectively. In the severely low BMI group, the change in body weight (ß = 0.34, p = 0.006) and quadriceps thickness at admission (ß = -0.62, p < 0.001) were significantly and independently related to the change in quadriceps thickness (R2 = 0.645, f2 = 1.817, statistical power = 1.000). In the moderately low BMI and non-low BMI groups, there were no factors that were significantly and independently related to the change in quadriceps thickness. CONCLUSIONS: The results of this study suggest that change in body weight is positively related to the change in muscle mass of the quadriceps in older inpatients with severely low BMI according to the GLIM criteria. These results imply the importance of body weight management for older inpatients with severely low BMI perspective from the muscle mass of the quadriceps.

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Background/Objectives Enhancing preoperative quadriceps strength and mitigating quadriceps strength loss due to total knee arthroplasty (TKA) is crucial for post-TKA recovery. This study compared the safety and effect of a four-week preoperative regimen of low-load resistance training with blood flow restriction (LLRT-BFR) with those of low-intensity resistance training with slow movement and tonic force generation (LST) on the pre- and postoperative quadriceps strength in patients undergoing TKA. Methods In this randomized controlled trial, 22 patients were assigned to either the LLRT-BFR (n=11) or LST (n=11) group. Primary outcomes included changes in quadriceps strength before and after the intervention and surgery. To assess safety, we monitored D-dimer and high-sensitivity C-reactive protein levels pre- and post-intervention. Statistical analysis involved independent samples t-tests and Mann-Whitney U tests for group comparisons of quadriceps strength changes. Additionally, a two-way repeated-measures analysis of variance was used to assess safety parameters. Results No significant differences were observed between the BFR and LST groups in terms of the rate of increase in quadriceps strength pre- and post-intervention (BFR: median 12.1%, interquartile range -0.8% to 19.5%; LST: median 6.2%, interquartile range 2.7% to 14.7%; p>0.99) or in the rate of reduction in quadriceps strength pre- and post-surgery (BFR: mean -72.4%, standard deviation ±11.2%; LST: mean -75.3%, standard deviation ±12.2%; p=0.57). Safety assessments showed no significant main effects of time, group, or interaction on the safety parameters (all p>0.05). Conclusions LLRT-BFR and LST demonstrated comparable effects on quadriceps strength before and after intervention and surgery in patients undergoing TKA. The lack of significant changes in the safety parameters supports the safety profile of both interventions, indicating their suitability for preoperative conditioning in patients scheduled for TKA.

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Background: Variation in stiffness, fixation methods, and donor-site morbidity after anterior cruciate ligament reconstruction (ACLR) with different graft types and with anterior cruciate ligament suture repair (ACLSR) can lead to differences in dynamic knee laxity and consequent differences in posttraumatic osteoarthritis (PTOA) development. Purpose: To compare the incidence of PTOA between different graft types used for primary ACLR and between primary ACLR and ACLSR. It was hypothesized that the incidence of PTOA would vary between ACLR with different autografts and allografts and between ACLR and ACLSR. Study Design: Systematic review; Level of evidence, 1. Methods: A search of the literature was performed to identify all randomized controlled trials (RCTs) comparing radiographic evidence of PTOA after ACLR between different graft types-hamstring tendon (HT) autograft, bone-patellar tendon-bone (BPTB) autograft, quadriceps tendon autograft, and allograft-and between ACLR and ACLSR. The minimum follow-up was 2 years. Study quality was assessed using the modified Coleman Methodology Score. A meta-analysis was performed to determine whether there was a difference in the incidence of PTOA between the different graft types and between ACLR and ACLSR. Results: Eleven randomized controlled trials were included in the meta-analysis-HT: 440 patients (mean follow-up, 9.7 years); BPTB: 307 patients (mean follow-up, 11.8 years); allograft: 246 patients (mean follow-up, 5 years); ACLSR, 22 patients (5 years). No study reporting the incidence after ACLR with quadriceps tendon was included. The study quality ranged from 70 to 88. The meta-analysis indicated no significant difference in the incidence of PTOA between graft types used for ACLR and between ACLR and ACLSR (risk ratios: HT vs BPTB, 1.05; HT vs allograft, 0.81; BPTB vs allograft, 0.82; HT vs ACLSR, not estimable [P > .05 for all]). The combined number of patients with PTOA in all studies per graft type showed that patients who underwent ACLR with a BPTB autograft had the highest percentage of PTOA (HT, 23.4%; BPTB, 29.6%; allograft, 8.1%; ACLSR, 0%). However, excluding studies with a follow-up <5 years resulted in similar outcomes for patients with an HT autograft and a BPTB autograft. Conclusion: This meta-analysis reported no difference in the incidence of PTOA between graft types used for ACLR and between ACLR and ACLSR. More research is necessary to make a reliable conclusion about which technique is associated with the lowest incidence of PTOA after ACL surgery.

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PURPOSE: To investigate sex-based recovery differences in patients undergoing anterior cruciate ligament reconstruction (ACLR) with a hamstring (HT) or quadriceps (QT) tendon autograft. METHODS: This study included 97 patients, including 50 females (HT = 25, QT = 25) and 47 males (HT = 24, QT = 23), assessed presurgery and at 12- and 24-month postoperatively via surveys, laxity, isokinetic knee extensor and flexor torque and a 6-hop performance battery. Limb symmetry indices (LSIs) were calculated. Outcomes were compared between males and females, as well as within each graft type. RESULTS: Males reported significantly higher Tegner scores at 12 (p = 0.029) and 24 (p = 0.031) months, Anterior Cruciate Ligament Return to Sport after Injury scores at 12 (p = 0.009) and 24 (p = 0.010) months, and a significantly higher lateral hop LSI at 12 (p = 0.045) months, knee extensor torque LSI at 12 (p = 0.020) months, and knee flexor torque LSI at 12 (p = 0.001) and 24 (p = 0.039) months. Females undergoing ACLR with a QT (vs. HT) graft demonstrated a lower knee extensor torque LSI at 12 (p = 0.006) months, a lower lateral hop LSI at 12 (p = 0.038) months, and a lower medial hop LSI at 12 (p = 0.042) months. CONCLUSIONS: Females reported less activity and psychological readiness, as well as strength symmetry. Furthermore, the recovery of quadriceps strength and hop symmetry was delayed in females (vs. males) undergoing ACLR with a QT graft. A better understanding of these differences will assist in counselling on expectations, determining the most appropriate graft construct and permitting more targeted rehabilitation. LEVEL OF EVIDENCE: Level IV.

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BACKGROUND: The reported incidence of posttraumatic knee osteoarthritis (PTOA) after primary anterior cruciate ligament reconstruction (ACLR) varies considerably. Further, there are gaps in identifying which patients are at risk for PTOA after ACLR and whether there are modifiable factors. PURPOSE: To (1) determine the incidence of PTOA in a primary ACLR cohort and (2) identify patient and perioperative factors associated with the development of PTOA after primary ACLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data from the Kaiser Permanente ACLR Registry were used to conduct a cohort study. Patients who had undergone primary ACLR without a previous diagnosis of osteoarthritis were identified (2009-2020). The crude incidence of PTOA was calculated using the Aalen-Johansen estimator with a multistate model. The association of patient and operative factors with the development of PTOA after primary ACLR was modeled as a time to event using multistate Cox proportional hazards regression. Models stratified by age (<22 and ≥22 years) were also conducted because of the effect modification of age. RESULTS: The study sample included 41,976 cases of primary ACLR. The incidence of PTOA was 1.7%, 5.1%, and 13.6% at 2, 5, and 10 year follow-ups, respectively. Risk factors for PTOA that were consistently identified in the overall cohort and age-stratified groups included a body mass index ≥30 versus <30 and an allograft or quadriceps tendon autograft versus a hamstring tendon autograft. Patients presenting with knee pain after ACLR were further identified when considering postoperative factors. Other risk factors for PTOA in the overall cohort included age ≥22 versus <22 years, bone-patellar tendon-bone autograft versus hamstring tendon autograft, hypertension, cartilage injury, meniscal injury, revision after primary ACLR with concomitant meniscal/cartilage surgery, multiligament injury, other activity at the time of injury compared with sport, and tibial tunnel drilling technique rather than the anteromedial portal. CONCLUSION: Knee pain after ACLR may be an early sign of PTOA. Surgeons should consider the adverse associations of a higher body mass index and an allograft or quadriceps tendon autograft with the development of PTOA, as these were factors identified with a higher risk, regardless of a patient's age at the time of primary ACLR.

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BACKGROUND: The ideal graft for anterior cruciate ligament (ACL) reconstruction (ACLR) in young athletes has a high return-to-sport (RTS) rate and a low reinjury rate. Quadriceps tendon autografts are being used with increasing frequency for ACLR in this population, despite a paucity of evidence to support their use. PURPOSE: To report the RTS rate, ipsilateral reinjury rate, and contralateral ACL injury rate in a young athletic population undergoing primary ACLR using an all-soft tissue quadriceps tendon (ASTQT) autograft. STUDY DESIGN: Cases series; Level of evidence, 4. METHODS: Patients aged 14 to 22 years who underwent primary ACLR using an ASTQT autograft by a single surgeon between January 1, 2005, and April 30, 2020, were identified via electronic medical records and contacted ≥24 months after ACLR to complete a survey regarding subsequent ipsilateral or contralateral ACL injuries and RTS. Patients who had undergone previous ACLR (ipsilateral or contralateral) were excluded. RESULTS: A total of 656 patients (330 male, 326 female; mean age, 17.9 years) were identified, and 395 patients completed the survey (60.2%; 174 male, 221 female; mean age, 17.8 years) with a mean follow-up of 73 ± 29 months (range, 24-139 months). The RTS rate was high (male: 87.7%; female: 82.8%; P = .19). Male and female patients had similar rates of revision ACLR (male: 12.6%; female: 10.0%; P = .40) and contralateral ACL injuries (male: 13.8%; female: 11.3%; P = .46). CONCLUSION: A high RTS rate and similar rates of ipsilateral and contralateral ACL injuries were found for male and female patients in a young athletic population undergoing primary ACLR using an ASTQT autograft. These results help one to better understand the utility of ASTQT grafts to support successful ACLR in young athletic populations, for which ASTQT grafts appear to yield favorable outcomes.

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Background A common knee joint disorder is injury to the anterior cruciate ligament (ACL), which often requires surgery. Proper pain control after the surgery facilitates fast recovery and prevents chronic pain. To provide analgesia for knee procedures, the use of opioids, non-steroidal anti-inflammatory medications, and regional techniques are commonly employed. This study aims to evaluate the efficacy of adductor canal block (ACB) and femoral nerve block (FNB) for postoperative pain management after anterior cruciate ligament reconstructions (ACLRs). Methodology This prospective interventional study included 30 participants scheduled for patellar graft ACLR. They were assigned into groups, i.e., ACB and FNB, with 15 patients each. The evaluation occurred one day before the operation, and all surgical procedures were performed using spinal anesthesia. During the postoperative period, a 10-point visual analog scale (VAS) was utilized to quantify pain intensity at the end of the surgery and at various intervals after the surgery. Patients with a VAS score greater than 4 received either FNB or ACB using bupivacaine 0.125%. Duration of analgesia time, power of quadriceps muscle, and neurologic complications were documented. Results No statistically significant value was observed in the mean duration of analgesia between the patients in ACB (348.33 minutes) and the patients in FNB (363.06 minutes). No motor block was observed in 12 patients who received ACB, while only four patients had a motor-sparing effect among those who received FNB. No neurological adverse effects were observed in the study participants. Conclusions ACB provides an equal duration of analgesia similar to FNB, and ACB significantly spares motor strength and maintains higher quadriceps power than FNB.

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Arthrogenic Muscle Inhibition (AMI) is a phenomenon observed in individuals with joint injury or pathology, characterized by a reflexive inhibition of surrounding musculature, altered neuromuscular control, and compromised functional performance. After anterior cruciate ligament reconstruction (ACLR) one of the most obvious consequences of AMI is the lack of quadriceps activation and strength. Understanding the underlying mechanisms of AMI is crucial for developing effective therapeutic interventions. The surgical procedure needed to reconstruct the ACL has biochemical et physiological consequences such as inflammation, pain, and altered proprioception. These alterations contribute to the development of AMI. Therapeutic interventions aimed at addressing AMI encompass a multidimensional approach targeting pain reduction, inflammation management, proprioceptive training, and quadriceps activation. Early management focusing on pain modulation through modalities like ice, compression, and pharmacological agents help mitigate the inflammatory response and alleviate pain, thereby reducing the reflexive inhibition of quadriceps. Quadriceps activation techniques such as neuromuscular electrical stimulation (NMES) and biofeedback training aid in overcoming muscle inhibition and restoring muscle strength. NMES elicits muscle contractions through electrical stimulation, bypassing the inhibitory mechanisms associated with AMI, thus facilitating muscle activation and strength gains. Comprehensive rehabilitation programs tailored to individual needs and stage of recovery are essential for optimizing outcomes in AMI. The objective of this clinical viewpoint is to delineate the significance of adopting a multimodal approach for the effective management of AMI, emphasizing the integration of pain modulation, proprioceptive training, muscle activation techniques, and manual therapy interventions. Highlighting the critical role of early intervention and targeted rehabilitation programs, this article aims to underscore their importance in restoring optimal function and mitigating long-term complications associated with AMI.