Muscle function, Lysholm score and hop performance in individuals with clinical indications for the combined reconstruction of the anterior cruciate and the anterolateral ligaments of the knee: A cross-sectional study

Carvalho, Adriana; Novaes, Marilia; Sauer, Juliana; Demange, Marco Kawamura; Helito, Camilo Partezani; João, Silvia Maria Amado

doi:10.1016/j.clinsp.2023.100267

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Original articles • Clinics 78 • 2023 • https://doi.org/10.1016/j.clinsp.2023.100267 linkcopy

Muscle function, Lysholm score and hop performance in individuals with clinical indications for the combined reconstruction of the anterior cruciate and the anterolateral ligaments of the knee: A cross-sectional study

Authorship SCIMAGO INSTITUTIONS RANKINGS

Highlights

Studies have shown worse rotational stability in the presence of a supposed ALL injury combined with an ACL injury. However, there is no evidence, so far, on how individuals behave regarding muscle strength and functionality.
Knee and hip muscular functions are impaired after an ACL injury and do not seem to be influenced or worsened in individuals with greater rotational instability with clinical indications for combined reconstruction of the anterior cruciate and the anterolateral ligaments of the knee.
The ACL+ALL group showed a significantly shorter distance achieved in the Crossover Hop Test than the other groups, as well as the reports of more pain during the tests.

Abstract

Objective To evaluate hip and knee muscular function, knee patient-reported outcome measures and hop performance in patients with a clinical indication for combined ACL+ALL reconstruction surgery compared to patients with an isolated ACL reconstruction surgery indication (preoperative phase) and to a control group.

Design Cross-sectional study.

Methods The sample was composed of male individuals, aged between 18 and 59 years, divided into three groups (ACL, ACL+ALL and Control). Isokinetic dynamometry was performed for the flexor and extensor knee muscles and for the hip abductors and adductors. SLHT, COHT and the Lysholm score were performed. Pain, swelling, and thigh trophism were also measured.

Results The study participants were 89 male individuals: 63 in the injury group and 26 in the control group. After applying the criteria for an ALL reconstruction indication, 33 patients were assigned to the ACL Group and 30 patients to the ACL+ALL Group. Regarding knee and hip muscle function, both groups presented worse results when compared to the control group, however, did not show significant differences compared to each other. Regarding the functional variables, the ACL+ALL group showed a significantly shorter distance achieved in the Crossover Hop Test than the other groups, as well as more pain during the tests.

Conclusion Knee and hip muscular functions are impaired after an ACL injury and do not seem to be influenced or worsened in individuals with greater rotational instability with clinical indications for combined reconstruction of the anterior cruciate and the anterolateral ligaments of the knee.

Keywords Anterior cruciate ligament injuries; Knee injuries; Muscle strength dynamometer; Lysholm knee score

	ACL Group (n= 33)	ACL+ALL Group (n= 30)	Control Group (n= 26)	p-value
Age (years)	27 ± 8	30 ± 10	28 ± 3	0.506
Height (cm)	177 ± 7^a a p< 0.05 compared to the ACL+ALL Group. † p< 0.05 compared to the Control Group. ¥ p< 0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; cm, centimeters; kg, kilograms.	174 ± 7	178 ± 8^a a p< 0.05 compared to the ACL+ALL Group. † p< 0.05 compared to the Control Group. ¥ p< 0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; cm, centimeters; kg, kilograms.	0.019
Weight (kg)	82 ± 13	79 ± 13	82 ± 13	0.553
Physically active individuals (n)	25 (83%)	20 (61%)	21 (81%)	0.079
Dominance (right dominance %)	27 (90%)	28 (85%)	23 (88%)	0.815
Time since injury (months)	33 ± 36	31 ± 37	‒	<0.001
Lateral meniscus injury (n)	3 (10%)	9 (27%)	0 (0%)	0.165
Medial meniscus injury (n)	13 (43%)	9 (27.3%)	0 (0%)	0.165
Right limb injured (%)	19 (63%)	14 (42%)		0.147
Associated injuries (%)	20 (67%)	21 (64%)	‒	0.742
Injury during sports activity (% of individuals)	27 (90%)	29 (88%)	2 (100%)	0.653

	ACL Group	ACL+ALL Group	Control Group	p-value
Lysholm score	72 ± 15^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	68 ± 21^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	98 ± 4	<0.001
SLHT distance (cm) AL	101 ± 33^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	83 ± 38^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	129 ± 25	<0.001
SLHT distance (cm) CL	129 ± 28	119 ± 49^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	130 ± 23	0.041
COHT distance (cm) AL	285 ± 92^a a p <0.05 compared to the ACL+ALL Group. ,^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	215 ± 104^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	400 ± 92	<0.001
COHT distance (cm) CL	325 ± 89^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	285 ± 96^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	400 ± 92	<0.001
SLHT pain AL (%)	6 (21%)^a a p <0.05 compared to the ACL+ALL Group. ,^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	16 (48%)^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	2 (4%)	<0.001
SLHT pain CL	0 (0%)	0 (0%)	2 (4%)	0.295
COHT pain AL (%)	7 (25%)^a a p <0.05 compared to the ACL+ALL Group. ,^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	16 (50%)^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	1 (2%)	<0.001
COHT pain CL	0 (0%)	0 (0%)	1 (2%)	0.552
SLHT instability AL (%)	10(36%)^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	15(45%)^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	1(2%)	<0.001
SLHT instability CL (%)	0 (0%)	0 (0%)	0 (0%)	NA
COHT instability AL (%)	10 (36%)^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	17 (53%)^b b p <0.05 compared to the Control Group. ¥ p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; NRS, Numerical Rating Scale; cm, centimeters; kg, kilograms; AL, Affected Limb; CL, Contralateral Limb; SLHT, Simple Leg Hop Test; COHT, Crossover Hop Test; NA, Not Applicable.	1 (2%)	<0.001
COHT instability CL	1 (4%)	1 (3%)	0 (0%)	0.417

Iso 60°/s	ACL Group	ACL+ALL Group	Control Group	p-value
Hip Abductors PT/BW (%)	135 ± 44	131 ± 42	129 ± 39	0.821
Hip Abductors TW (J)	284 ± 81	242 ± 79	272 ± 60	0.081
Knee Extensors PT/BW (%)	195 ± 49^b b p <0.05 compared to the Control Group. ¥p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; Iso, Isokinetic; PT/BW, Peak Torque/Body Weight; TW, Total Work; J, Joules; Ag/Ant, Agonist/Antagonist relation.	220 ± 69^b b p <0.05 compared to the Control Group. ¥p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; Iso, Isokinetic; PT/BW, Peak Torque/Body Weight; TW, Total Work; J, Joules; Ag/Ant, Agonist/Antagonist relation.	260 ± 71	0.000
Knee Flexors PT/BW (%)	128 ± 69	118 ± 50	127 ± 36	0.246
Knee Extensors TW (J)	657 ± 201^b b p <0.05 compared to the Control Group. ¥p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; Iso, Isokinetic; PT/BW, Peak Torque/Body Weight; TW, Total Work; J, Joules; Ag/Ant, Agonist/Antagonist relation.	676 ± 211^b b p <0.05 compared to the Control Group. ¥p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; Iso, Isokinetic; PT/BW, Peak Torque/Body Weight; TW, Total Work; J, Joules; Ag/Ant, Agonist/Antagonist relation.	886 ± 216	0.000
Knee Flexors TW (J)	385 ± 122	335 ± 148	472 ± 113	0.691
Knee Ag/Ant (%)	58 ± 13^a a p <0.05 compared to the ACL+ALL Group. ,^b b p <0.05 compared to the Control Group. ¥p <0.05 compared to the ACL Group. ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; Iso, Isokinetic; PT/BW, Peak Torque/Body Weight; TW, Total Work; J, Joules; Ag/Ant, Agonist/Antagonist relation.	49 ± 13	49 ± 7	0.016

Iso 120°/s	ACL Group	ACL+ ALL Group	Control Group	p-value
Knee Extensors PT/BW (%)	176 ± 38^†	192 ± 47	221 ± 45	0.003
Knee Flexors PT/BW (%)	97 ± 21^†	100 ± 33	117 ± 28	0.032
Knee Extensors TW (J)	575.69 ± 163.31^†	586 ± 157^†	749 ± 168	0.000
Knee Flexors TW (J)	329 ± 99	303 ± 113^†	400 ± 102	0.008
Knee Ag/Ant (%)	56 ± 11	52 ± 12	53 ± 7	0.411

Isokinetic evaluation	Time since injury (months)	Lysholm score	SLHT (cm)	COHT (cm)	NRS (0‒10)
Knee Extensors	−0.017	0.414	0.579^a a Moderate correlation coefficient.	0.528^a a Moderate correlation coefficient.	−0.094
PT/BW (%)
60°/s
Affected limb
Knee Flexors	−0.059	0.210	0.480	0.421	−0.111
PT/BW (%)
60°/s
Affected limb
Knee Extensors	0.185	0.425	0.464	0.476	0.027
TW (J)
60º/s
Affected limb
Knee Flexors	0.055	0.407	0.447	0.535^a a Moderate correlation coefficient.	−0.037
TW (J)
60°/s
Affected limb
Ag/Ant	−0.232	−0.101	−0.022	0.036	−0.051
60°/s
Affected limb
Knee Extensors	−0.045	0.309	0.700^b b Strong correlation coefficient. PT/BW, Peak Torque/Body Weight; TW, Total Work; J, Joules; Ag/Ant, Agonist/Antagonist relation; cm, Distance measured in centimeters; SLHT, Single Leg Hop Test; COHT, Crossover Hop Test; NRS, Numerical Rating Scale.	0.632^a a Moderate correlation coefficient.	−0.105
PT/BW (%)
120°/s
Affected limb
Knee Flexors	−0.092	0.233	0.566^a a Moderate correlation coefficient.	0.579^a a Moderate correlation coefficient.	0.011
PT/BW (%)
120°/s
Affected limb
Knee Extensors	0.087	0.301	0.529^a a Moderate correlation coefficient.	0.544^a a Moderate correlation coefficient.	0.081
TW (J)
120°/s
Affected limb
Knee Flexors	0.005	0.200	0.396	0.503^a a Moderate correlation coefficient.	0.164
TW (J)
120°/s
Affected limb
Ag/Ant	−0.070	−0.003	−0.091	0.022	0.196
60°/s
Affected limb

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p< 0.05 compared to the ACL+ALL Group.

† p< 0.05 compared to the Control Group.

¥ p< 0.05 compared to the ACL Group.

ACL+ALL, Combined Reconstruction Indication Group; LCA, Isolated Reconstruction Indication Group; cm, centimeters; kg, kilograms.