Knee Surg Sports Traumatol Arthrosc (2010) 18:317–324

DOI 10.1007/s00167-009-0931-9

KNEE

Knee flexor strength after ACL reconstruction: comparison

between hamstring autograft, tibialis anterior allograft,
and non-injured controls
Sarah Landes • John Nyland • Brian Elmlinger •

Ed Tillett • David Caborn

Received: 1 July 2009 / Accepted: 8 September 2009 / Published online: 7 November 2009
Ó Springer-Verlag 2009

Abstract Hamstring muscle group dysfunction following when a tibialis anterior allograft is used. Early identifica-
anterior cruciate ligament reconstruction (ACL) using a tion of impaired knee flexor strength among this group and
semitendinosus–gracilis autograft is a growing concern. modified rehabilitation may reduce these deficits. Adding
This study compared the mean peak isometric knee flexor quantitative biomechanical testing of sprinting and sudden
torque of the following three groups: subjects 2 years fol- directional change movements to the standard physical
lowing ACL reconstruction using semitendinosus–gracilis therapy evaluation will better elucidate the clinical and
autografts (Group 1), subjects 2 years following ACL functional significance of the observed knee flexor strength
reconstruction using tibialis anterior allografts (Group 2), impairments and aid in determining sport specific activity
and a non-injured, activity-level-matched control group training readiness.
(Group 3). We hypothesized that Group 1 would have
greater mean involved lower extremity peak isometric knee Keywords Hamstring
Isometric
Arthroscopy

flexor torque deficits than the other groups. Handheld Patient outcome
dynamometry with subjects in prone and the test knee at
90° flexion was used to determine bilateral peak isometric
knee flexor torque. Group 1 (86.4 ± 11) and Group 2 Introduction
(80.5 ± 13) had similar 2000 IKDC Subjective Knee
Evaluation Form scores (P = NS). Group 1 had a mean Anterior cruciate ligament (ACL) reconstruction is evolv-
involved lower extremity peak isometric knee flexor torque ing from traditional single strand bone–patellar tendon–
deficit of -17.0 ± 14 Nm. Group 2 had a mean involved bone (BPTB) autograft use to innovative multiple bundle
lower extremity peak isometric knee flexor torque deficit of approaches that use a hamstring autograft or a tibialis
-0.8 ± 9 Nm. Group 3 (control) had a mean left and right anterior allograft. Some of these multiple bundle surgical
lower extremity peak isometric knee flexor torque differ- techniques are believed to more closely simulate native
ence of -0.7 ± 14 Nm. Group 1 had decreased involved ACL anatomy and function [10, 14]. One of the important
lower extremity peak isometric knee flexor torque com- decisions the knee surgeon must make is selecting which
pared to Groups 2 and 3 (two-way ANOVA; group 9 side tendon graft to use. Reports have shown that tibialis
interaction P \ 0.05, Tukey HSD = 0.008). Long-term anterior allografts provide similar strength in single loop
knee flexor strength deficits exist following hamstring (two strands) configurations to quadrupled hamstring
autograft use for ACL reconstruction that does not occur autografts [15, 27]. Previous reports have shown good self-
reported patient function at 2 years following ACL
reconstruction using tibialis anterior allografts [26].
S. Landes
J. Nyland (&)
B. Elmlinger
E. Tillett
Graft choice is an important surgical decision since each
D. Caborn type has its own inherent set of strengths and weaknesses.
Division of Sports Medicine, Department of Orthopaedic
Autogenous BPTB graft use has been the traditional stan-
Surgery, University of Louisville, 210 East Gray St.,
Suite 1003, Louisville, KY 40202, USA dard for ACL reconstruction with the benefits of having
e-mail: john.nyland@louisville.edu adequate tensile strength and bone-to-bone tunnel fixation,

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but the problems associated with its use may include Materials and methods
anterior knee pain, patellofemoral joint arthritis, long-term
quadriceps femoris muscle group dysfunction, and occa- A sample size estimate revealed that 18 subjects per group
sional patellar fracture [17, 21, 22]. Soft tissue allografts would be needed based on a mean side-to-side difference
have no associated donor morbidity and have high tensile of 10 ± 12 Nm for subjects in the ACL reconstruction
strength [15], but also may have greater disease transmis- groups and a mean side-to-side difference of 0 ± 12 Nm
sion or immune response risks [8], take longer to incor- for control group subjects (alpha level = 0.05, statistical
porate, remodel less completely, and have higher failure power of 80). Three groups of 20 subjects provided
rates [20, 28]. informed consent to participate in this institutional review
Because of its sufficient length and strength in an board approved study (Table 1). Surgical group subjects
autogenous form, hamstring autografts created from sem- (Group 1 and Group 2) were allowed to participate in the
itendinosus or combined semitendinosus–gracilis tendons study if they were between 18 and 55 years of age, were a
have become increasingly popular for ACL reconstruction minimum of 2-year status-post–ACL reconstruction, and if
[13, 14]. However, reports of complications associated they had undergone no other knee surgical procedure other
with hamstring autograft use, particularly among athleti- than minimal arthroscopic meniscal repair or partial men-
cally active individuals are increasing. In addition to con- iscectomy. Potential subjects were excluded from study
cerns that increased knee joint laxity may exist following participation if they had not been compliant with their
ACL reconstruction using a hamstring autograft compared rehabilitation protocol or if they could not participate in
to a BPTB autograft [3, 4, 12, 30], particularly in female stressful exercise activities because of other medical con-
patients [25], semitendinosus or semitendinosus–gracilis ditions. Control group subjects (Group 3) had to have no
autograft use has been associated with impaired involved previous knee injury history, and have full, pain-free,
lower extremity knee flexor and internal rotator strength [1, active bilateral knee range of motion.
2, 5–7, 11, 16, 18, 24, 29, 31, 34, 36, 37] (Table 1). Knee Group 1 consisted of 20 consecutive patients (13 men, 7
flexor strength impairments may contribute to functional women) that were 2.3 ± 0.4 years (minimum 2 years)
limitations during athletic high-speed sprinting and direc- post–ACL reconstruction with a semitendinosus–gracilis
tional change movements where hamstring muscle group autograft using Endobutton (Smith Nephew, Mansfield,
activation is increased [9, 19, 32]. Based on their findings, MA) femoral fixation and bioabsorbable interference
Adachi et al. [1] recommended that ACL reconstruction screw (Arthrex, Naples, FL) tibial fixation. Thirteen of
with a knee flexor tendon autograft should not be per- these subjects also received a staple (3 M Health Care, St.
formed in athletically active individuals. Since allograft Paul, MN) for supplemental tibial fixation. Four subjects
use for ACL reconstruction does not require surgical in Group 1 underwent partial lateral meniscectomy, and
semitendinosus or gracilis harvest, knee flexor torque def- three underwent medial meniscus repair at the time of the
icits should not occur. However, direct comparisons have index ACL reconstruction procedure. Group 1 had a 2000
not been previously performed. IKDC Subjective Knee Evaluation Form score of
The purpose of this study was to compare peak isometric 86.4 ± 11. This group data set has been previously
knee flexor torque differences between the involved and reported [8].
non-involved lower extremity of the following three Group 2 consisted of 20 consecutive patients (8 men, 12
groups: subjects 2 years following ACL reconstruction women) that were 2.4 ± 0.5 years (minimum 2 years)
using semitendinosus–gracilis autografts (Group 1), sub- post–ACL reconstruction with a tibialis anterior allograft
jects 2 years following ACL reconstruction using tibialis using bioabsorbable interference screw fixation at the femur
anterior allografts (Group 2), and a non-injured, activity- and tibia (Arthrex, Naples, FL). Three subjects in Group 1
level-matched control group (Group 3). We hypothesized underwent partial lateral meniscectomy, one underwent
that Group 1 subjects would have greater involved lower lateral meniscus repair, two underwent partial medial
extremity peak isometric knee flexor torque deficits than meniscectomy, and three underwent medial meniscus repair
the other groups. at the time of the index ACL reconstruction procedure.

Table 1 Subject demographics (median, range)

Age Weight Height 2000 IKDC self-reported
(years) (kg) (cm) activity level

Group 1 27, 18–45 77, 52–116 178, 152–191 3, 1–4

Group 2 30, 18–51 75, 44–141 173, 152–193 3, 2–4
Group 3 25, 18–45 76, 54–100 177, 150–202 3, 1–4

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Knee Surg Sports Traumatol Arthrosc (2010) 18:317–324 319

Group 2 had a 2000 IKDC Subjective Evaluation Form From these measurements, involved and non-involved
score of 80.5 ± 13. lower extremity peak isometric knee flexor torque was
Group 3 (control) consisted of 20 non-injured subjects determined.
(13 men, 7 women). Since the median 2000 IKDC Self-
Reported Activity Levels for Group 1 and Group 2 was 3
(well-trained and frequently sporting), Group 3 subjects Statistical methods
had an additional requirement to be actively participating
in recreational sports at the time of study participation. An unpaired t-test was used to compare 2000 IKDC Sub-
Chart review confirmed that both surgical groups were jective Knee Evaluation Form scores between surgical
compliant with their prescribed rehabilitation and condi- groups (Group 1 and Group 2). A one-way ANOVA and
tioning programs. Rehabilitation progression functional Tukey honest significant difference (HSD) post hoc test
milestones (postsurgical time to achievement) included was used to compare anterior knee laxity mean differences
dynamic neuromuscular knee control with pain-free walk- between the involved and non-involved lower extremity of
ing (1–2 weeks), complete active knee range of motion (2– each group. A two-way main and mixed (group 9 side)
4 weeks), restored knee extensor-flexor strength and power model ANOVA and Tukey HSD post hoc test and was used
through a combination of open (non-weightbearing) and to compare group and side differences for peak isometric
closed (weightbearing) kinetic chain therapeutic exercises knee flexor torque. An alpha level of P \ 0.05 was selected
(6–14 weeks), and three-dimensional dynamic knee sta- in indicate statistical significance. All statistical analysis
bility with single leg hopping and jump landing maneuvers was performed using Statistical Package for Social Sci-
(12–26 weeks). All subjects displayed 85–95% bilateral ences (SPSS) version 11.0 (SPSS, Chicago, IL).
equivalence with the single leg hop and 60°/s seated peak
isokinetic knee extensor-flexor testing prior to release to
sport specific training. All subjects initiated sport specific Results
training by 20–30 weeks postsurgery. Release to sports
activity for all subjects occurred at 6–10 months postsur- Group 1 (86.4 ± 11) and Group 2 (80.5 ± 13) did not
gery. Specific therapeutic exercise examples during differ for mean 2000 IKDC Subjective Knee Evaluation
achievement of various rehabilitation progression func- Form scores (P = NS). Arthrometric measurements
tional milestones have been previously reported [26]. revealed greater mean anterior knee laxity at the involved
Anterior knee laxity was measured via instrumented knee in Group 1 compared to the other groups (Table 2).
arthrometry at 133.4 N (KT-1000; MEDmetric, San Diego, Group 1 displayed lower involved lower extremity peak
CA) for each group. isometric knee flexor torque compared to the other groups
Subjects warmed-up on a stationary bicycle for 10 min (Table 3; Fig. 2).
at a comfortable self-selected pace and performed 5 min of
self-selected static lower extremity stretching prior to iso-
metric knee flexor strength testing. While in a supine
position lower leg length was measured from the center of
the lateral femoral condyle to the prominence of the lateral
malleolus using a tension-gated tape measure with the knee
extended. Handheld dynamometry (Model #01163,
Lafayette Instruments, Lafayette, IN, USA) was then per-
formed to determine bilateral peak isometric knee flexor
force. Subjects were tested in prone for three repetitions
with the test knee at 90° flexion and with the dynamometer
placed immediately proximal to the level of the promi-
nence of the lateral malleolus, as previously described
(Fig. 1) [8]. Tests were performed alternating between the
non-involved and involved lower extremity to eliminate
order bias. Two investigators performed all measurements.
Measurements displayed good inter-tester (ICC = 0.89)
reliability. From this data, peak involved and non-involved
lower extremity isometric knee flexor torque (Nm) were
determined by multiplying mean peak isometric knee Fig. 1 Handheld dynamometry of peak isometric knee flexor torque
flexor force (N) for the three trials by lower leg length (m). in prone position at 90° knee flexion

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Table 2 One-way ANOVA with Tukey HSD post hoc test revealed greater involved–non-involved lower extremity anterior knee laxity in
Group 1 (STG autograft) compared to Group 3 (control)
Non-involved side (mm) Involved side (mm) Mean difference (mm) Median difference (mm)

Group 1 6.0 ± 2.2 8.7 ± 2.1 ?2.7* ?3

Group 2 6.0 ± 2.5 7.5 ± 2.7 ?1.5 ?1.5
Group 3 6.6 ± 2.9 (left knee) 5.7 ± 2.6 (right knee) -0.9 ?1.0
Group 2 (tibialis anterior allograft) and Group 3 (control) did not differ
* One-way ANOVA mean square = 17.2, F = 4.8, P = 0.012, Tukey HSD post hoc test: Group 1 [ Control, P = 0.008; Group 2 and Group 3
did not differ P = NS

Table 3 Two-way ANOVA with main and interaction (group 9 - non-involved lower extremity of Group 1 or compared to either the
side) comparison revealed that Group 1 had a greater involved lower involved or non-involved lower extremity of Groups 2 or 3
extremity peak isometric knee flexor torque deficit compared to the

Non-involved side (Nm) Involved side (Nm) Mean difference (Nm)

Group 1 (STG autograft) 73.2 ± 15 56.2 ± 19* -17*

Group 2 (tibialis anterior allograft) 72.3 ± 24 71.5 ± 21 -0.8
Group 3 (control) 71.4 ± 19 (left) 70.7 ± 19 (right) -0.7
Type III sum of squares df Mean square F P

Group 9 side 2,595.6 2 1,297.8 3.6 0.03*

Group 1,344.2 2 672.1 1.9 NS
Side 838.3 1 357.1 2.3 NS

* Tukey HSD post hoc test revealed that Group 1 involved lower extremity knee flexor torque was significantly lower than the other groups
(P \ 0.05)

impairments than subjects who underwent ACL recon-

struction using a tibialis anterior allograft or a non-injured
control group, proving our study hypothesis. Many previ-
ous studies have identified how semitendinosus–gracilis [1,
2, 5, 7, 11, 16, 18, 24, 29, 31, 34, 36, 37] or semitendinosus
[1, 6, 16, 24, 29, 31, 37] autograft use for ACL recon-
struction creates knee flexor [1, 2, 6, 7, 11, 16, 18, 24, 29,
31, 37] or knee internal rotator [5, 29, 34, 36] torque def-
icits (Table 4). However, only one previous report evalu-
ated an ACL reconstruction group that used allograft tissue
[1] and no previous study directly compared the isometric
knee flexor torque of subjects following ACL reconstruc-
tion using a semitendinosus–gracilis autograft with similar
subjects who underwent ACL reconstruction using a tibi-
alis anterior allograft, and a non-injured, activity-level-
Fig. 2 Involved lower extremity mean peak isometric knee flexor matched control group.
torque (mean ± 95% confidence interval) for the semitendinosus Additionally, this study tested peak isometric knee
(STG) autograft group (Group 1) was significantly lower than Group flexor torque in prone position for all subject groups.
1 non-involved lower extremity, or for either the involved or non-
Elmlinger et al. [11] suggested that peak isometric knee
involved lower extremity isometric knee flexor torque of Group 2
(tibialis anterior allograft = Tib. Ant. allograft) and Group 3 (control) flexor strength testing in prone more closely replicated the
hamstring muscle group length-tension relationship of
Discussion upright function than seated testing. Prone isokinetic knee
flexor strength testing of subjects following ACL recon-
The most important study finding was that subjects that struction using a semitendinosus–gracilis autograft
underwent ACL reconstruction using a semitendinosus– revealed earlier peak torque development followed by a
gracilis autograft had greater knee flexor strength sharp decrease as the knee flexion angle increased [11].

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Table 4 Reported knee flexor torque deficits after ACL reconstruction with hamstring autograft
Study Graft Follow-up Study findings

Adachi et al. [1] Fascia lata allograft 2 years, 11 months Greater peak isokinetic knee flexor torque deficit,
(n = 14), ST (n = 26), knee flexion deficit, and peak isokinetic knee
STG (n = 18) flexor torque shifted to lesser flexion angle in ST
and STG groups
Armour et al. [5] STG (n = 30) 2 years Decreased peak isokinetic knee internal rotator at
torque 60, 120, and 180°/s
Elmlinger et al. [11] STG (n = 20) 2 years Decreased peak isometric knee flexor torque at 90°
and 120° flexion, isokinetic torque pattern and
total work differences at greater knee flexion
angles
Hiemstra et al. [16] BPTB (n = 24), ST 30.4 ± 10.5 months No peak isokinetic knee flexor torque differences
(n = 7), STG (n = 9), between ST and STG groups. Pooled data revealed
control (n = 30) a knee flexor torque deficit compared to BPTB
group and a 50% torque deficit compared to
control group
Lautamies et al. [18] BPTB (n = 175), 5 years Peak isokinetic knee extensor torque was greater in
STG (n = 113) the STG group. Peak isokinetic knee flexor torque
was greater in the BPTB group. 68% of the STG
group had a single-leg hop ratio C90%, 31% were
75–89%, and 1% \ 75%. BPTB group single-leg
hop ratios were 72%, 21%, and 7%, respectively.
IKDC, Tegner, Lysholm, and Kujala surveys did
not differ
Nakamura et al. [24] ST (n = 49), STG (n = 25) 2 years Decreased peak isokinetic knee flexor torque and
decreased torque at 90° knee flexion in both
groups
Segawa et al. [29] STG (n = 30), ST (n = 32) 1 year Greater peak isokinetic knee internal rotator torque
deficits postsurgery in the STG group. ST use
alone was preferred, particularly among females
Tashiro et al. [31] ST (n = 49), STG (n = 36) 6 months Decreased peak isokinetic knee flexor torque at 70°,
90°, and 110° knee flexion in both groups. Both
groups also had decreased peak isometric torque at
90° knee flexion
Torry et al. [34] BPTB (n = 34), 53.1 ± 36 months Larger peak isokinetic knee internal rotator torque
STG (n = 34), deficits at 60, 120, and 180°/s in the STG group.
control (n = 34) BPTB group had decreased peak isokinetic knee
external rotator torque
Viola et al. [36] STG (n = 23) 51 ± 40 months Decreased peak isokinetic knee internal rotator
torque
Yasuda et al. [37] STG (ipsilateral) n = 31, First postoperative year Decreased peak isokinetic knee flexor torque with
contralateral) n = 34) ipsilateral harvest
Ageberg et al. [2] BPTB (n = 20) 3 ± 0.9 years Subjects with STG autograft had lower hamstring:
STG (n = 16) quadriceps muscle power ratios than subjects with
BPTB autograft
Bizzini et al. [7] BPTB (n = 87) Mean = 11, Peak knee flexor torque deficit in the STG group
STG (n = 66) range = 9–13 months
Asagumo et al. [6] STB 33 months Similar peak knee extensor and flexor isokinetic
(single bundle, n = 52); torque deficits between single bundle and double
(double bundle, n = 71) bundle ACL reconstruction using STG autografts
ST semitendinosus; STG semitendinosus–gracilis; BPTB bone–patellar tendon–bone

Therefore, peak isometric knee flexor strength testing study, a non-injured, activity-level-matched control group
performed in prone at knee flexion angles C90° may also was included to establish natural lower extremity side-to-
provide a more valid and functionally generalizable mea- side peak isometric knee flexor torque differences and a
surement of knee flexor torque deficits associated with group that underwent ACL reconstruction using a tibialis
hamstring autograft use for ACL reconstruction. In this anterior allograft was included to determine the influence

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of ACL reconstruction without the potential sensorimotor semitendinosus–gracilis autograft tissue. Further study is
dysfunction associated with initial graft harvest or with also needed to establish the true functional limitation sig-
long-term loss of two knee flexor agonists. nificance of these knee flexor strength impairments.
We found that Group 1 subjects (semitendinous-gracilis Although statistically significant mean differences for the
autograft) had a greater mean peak isometric knee flexor 2000 IKDC Subjective Knee Evaluation Form were not
torque deficit at their involved lower extremity than both evident, the statistical power was low. Additionally, the
Group 2 (tibialis anterior allograft) and Group 3 (non- group that had the greater mean 2000 IKDC Subjective
injured, activity-level-matched control) subjects. Groups 2 Knee Evaluation Form score also had the larger involved
and 3 did not display statistically significant peak isometric lower extremity peak isometric knee flexor torque deficit.
knee flexor torque differences. These findings support Moisala et al. [23] reported insignificant overall knee flexor
previous studies that identified long-term residual knee strength deficits 4–7 years post–semitendinosus–gracilis
flexor strength deficits following semitendinosus–gracilis autograft use for ACL reconstruction; however, subjects
autograft use for ACL reconstruction [1, 2, 5, 7, 11, 16, 18, with increased anterior knee instability had decreased knee
24, 29, 31, 34, 36, 37] and verify that comparable strength flexor strength and lower Lysholm scores. Comparing
deficits do not exist with tibialis anterior allograft use. quantitative biomechanical measurements of high knee
Minimizing harvest site morbidity may help reduce knee flexor function during sprinting and running directional
flexor torque deficits following hamstring autograft harvest change activities as has been reported for single leg vertical
for ACL reconstruction. Tillett et al. [33] investigated the drop landings [35] with impairment level knee flexor tor-
location of the semitendinosus and gracilis bifurcation que measurements is needed to validate the clinical and
point in relation to the tibial tuberosity in cadaveric knees functional relevance of these findings. Evaluations such as
and determined that the ideal harvest incision is located this might provide an important addition to the standard
slightly more medial than what is commonly used. Use of physical therapy evaluation to help better determine sport
this procedure may decrease local tissue damage from graft specific activity training readiness. Similar comparisons
harvest and minimize the extent of injury to the saphenous with 2000 IKDC Subjective Knee Evaluation Form scores
nerve and its branches [33]. Elmlinger et al. [11] reported would also be useful to improve our understanding of the
that sensation at the semitendinosus–gracilis harvest site in validity of this self-report instrument to identify subtle
addition to peak isokinetic knee flexor strength (prone functional limitations among athletically active individuals
testing) and Short Form-36 role physical score predicted following ACL reconstruction. This study is limited in that
80% of medial single leg hop capability at the involved it is a retrospective study of subjects who underwent ACL
lower extremity following ACL reconstruction using a reconstruction using semitendinosus–gracilis autograft or
semitendinosus–gracilis autograft. Since sensory nerve tibialis anterior allograft tissues performed by two different
injury also has functional outcome implications the mor- surgeons. Ideally, a prospective study design with one
bidity associated with initial semitendinosus–gracilis har- surgeon randomly assigning a graft type with all other
vest may contribute to long-term knee flexor dysfunction surgical and rehabilitation variables being identical would
through both sensory and motor mechanisms. have taken place with a larger patient group. Despite these
This study and others [1, 2, 5–7, 11, 16, 18, 24, 29, 31, limitations, we believe the study has provided further
34, 36, 37] have reported knee flexor and/or internal rotator evidence verifying the long-term effects of semitendino-
torque deficits from 6 months to 5 years post–ACL sus–gracilis autograft use for ACL reconstruction, in the
reconstruction following hamstring autograft use despite form of involved lower extremity knee flexor strength
rehabilitation and conditioning program compliance. impairments that do not occur with tibialis anterior allo-
Although subjects who underwent ACL reconstruction graft use.
using semitendinosus–gracilis autografts were compliant
with rehabilitation, the impact that the protocol might have
had on alleviating knee flexor strength impairments had Conclusions
earlier and more focused active and resistive knee flexion-
internal rotation and combined knee flexion–hip extension Mean involved lower extremity peak isometric knee flexor
exercises been performed in upright or prone positions at torque deficits are greater at 2-year post–ACL reconstruc-
knee flexion angles C90° is unknown. tion when semitendinosus–gracilis autografts are used
Further study is needed to determine whether earlier and compared to when tibialis anterior allografts are used.
more focused rehabilitation concentration on the sensori- These differences are also greater than the side-to-side
motor aspects of knee flexion C90° performed in func- differences that naturally exist in non-injured subjects.
tionally relevant postures can help negate knee flexor Although involved lower extremity knee flexor torque
strength impairments following ACL reconstruction with impairments have been identified, it is not known if

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