Incidence and prognostic factors of knee extension deficits following anterior cruciate ligament reconstruction: A systematic review and meta-analysis of randomised controlled trials

ABSTRACT Background and aims Knee extension deficits complicate recovery from ACL injury and reconstruction, however the incidence of knee extension loss is not well defined. The aim of this review was to identify the incidence of loss of extension (LOE) following ACL rupture and reconstruction, explore the definitions of knee extension deficits reported and identify prognostic factors affecting LOE incidence. Methods and analysis A systematic search was conducted in Medline, Cochrane Library and PEDro for studies in publication up to November 2021, with no restrictions on publication year. References were screened and assessed for inclusion using predetermined eligibility criteria. Randomised controlled trials (RCTs) that quantified knee angle, loss of extension or incidence of extension deficit were included for quality assessment and data extraction. Statistical summaries were generated and meta-analyses performed in two parts to examine: (i) the probability of a datapoint being zero incidence compared to a non-zero incidence, and (ii) the relationship between the predictors and non-zero LOE incidence. Results A sample of 15494 papers were retrieved using the search criteria, with 53 studies meeting eligibility criteria. Pooled results from 4991 participants were included for analysis, with 4891 participants who had undergone ACLR. The proportion of included studies judged at an overall low risk of bias was small (7.8%). The observed group and study were the most important predictors for whether a datapoint reported an incidence of extension deficit. Time to follow up (P < 0.001) and graft type (P = 0.02) were found to have a significant influence on non-zero LOE incidence (%). Covariate adjusted estimates of average LOE indicated 1 in 3 patients presenting with LOE at 12months followup, reducing to 1 in 4 at 2 years. Conclusions This review examined the definitions for the measurement and interpretation of postoperative knee extension, and established the trajectory of knee extension deficit after ACL injury and reconstruction. While factors associated with loss of extension were identified, the exact trajectory of knee extension deficits were difficult to infer due to discrepancies in measurement techniques and patient variation. Clinicians should expect up to 1 in 3 patients to present postoperatively with loss of extension of at least 3 degrees, which may resolve in some patients over time. Future work should focus on LOE as a clinically relevant complication of ACL injury and treatment with appropriate attention to standardisation of definitions, measurements and better understanding of natural history. PROSPERO registration number CRD42018092295