Perioperative and Postoperative Factors Influence Quadriceps Atrophy and Strength After ACL Reconstruction: A Systematic Review

Background: Quadriceps dysfunction after anterior cruciate ligament (ACL) reconstruction is common and may affect return to sport due to resulting muscle atrophy and muscle weakness. Purpose: To systematically review the available literature regarding the impact of perioperative and postoperative interventions on quadriceps atrophy and loss of strength after ACL reconstruction. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review was performed in accordance with the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed, CINAHL, Cochrane Central, and Embase. The quality of evidence was evaluated using the Modified Coleman Methodology Score to determine consensus scores. Eligible level 1 or level 2 studies included interventions of perioperative nerve block, intraoperative tourniquet use, postoperative nutritional supplementation, and postoperative blood flow restriction training. Additionally, the included studies quantified postoperative quadriceps measurements such as thigh circumference, quadriceps cross-sectional area (CSA), isokinetic quadriceps strength, and/or quadriceps electromyographic (EMG) testing. Results: In total, 15 studies met stated inclusion and exclusion criteria with the following intervention types: perioperative nerve block (n = 4), intraoperative tourniquet use (n = 5), postoperative nutritional supplementation (n = 3), and postoperative blood flow restriction (n = 3). Intraoperative tourniquet use resulted in decreased thigh circumference and detrimental EMG changes in quadriceps function in 3 of the 5 included studies. Perioperative femoral nerve blocks were associated with transient decreases in postoperative quadriceps strength, persisting up to 6 weeks after surgery, in 2 of the 4 studies. Postoperative blood flow restriction training augmented quadriceps size and function after ACL reconstruction in 2 of 3 studies. Postoperative nutritional supplementation was associated with increased quadriceps volume and strength in 1 of the 3 studies examined. Conclusion: The peri- and postoperative factors reviewed here may influence quadriceps atrophy and strength after ACL reconstruction. Our results tentatively indicated that blood flow restriction training may be beneficial to the quadriceps after ACL reconstruction and that intraoperative tourniquet use and nerve block administration may be detrimental; however, the strongest finding was that all of these interventions would benefit from further level 1 and 2 evidence studies, including multicenter, randomized controlled trials with extended follow-up, to definitively determine their impact on return to activity.