KNEE

Factors affecting anterior knee pain following anatomicdouble-bundle anterior cruciate ligament reconstruction

Yasuo Niki • Akihiro Hakozaki • Wataru Iwamoto •

Hiroya Kanagawa • Hideo Matsumoto •

Yoshiaki Toyama • Yasunori Suda

Received: 2 April 2011 / Accepted: 21 October 2011 / Published online: 5 November 2011

� Springer-Verlag 2011

Abstract

Purpose The purpose of this study was to evaluate the

prevalence of anterior knee pain in anatomic double-bundle

anterior cruciate ligament (ACL) reconstruction and to

identify critical factors affecting postoperative anterior

knee pain development.

Methods Subjects comprised 171 patients (171 knees)

who underwent anatomic double-bundle ACL reconstruc-

tion with a follow-up period of C2 years. The proce-

dure used bone-patellar tendon-bone plus gracilis tendon

(BTB-G) in 56 knees, semitendinosus tendon (ST) in 71

knees, and ST-G in 44 knees. Clinical results and preva-

lence and severity of anterior knee pain were assessed at

3 months and 2 years postoperatively. Clinical variables

influencing anterior knee pain development at each post-

operative period were subjected to univariate analysis,

followed by logistic regression analysis to identify risk

factors for anterior knee pain.

Results Overall prevalences of anterior knee pain at

3 months and 2 years postoperatively were 42.0 and

11.1%, respectively. Use of BTB-G graft represented the

highest prevalence of anterior knee pain between the 3

different grafts (P = 0.001); however, this statistical sig-

nificance disappeared at 2 years postoperatively. Preva-

lence of postoperative extension deficit was significantly

higher in anterior knee pain-positive cohort than in anterior

knee pain-negative cohort at 3 months postoperatively.

Level of quadriceps strength was significantly lower, and

Lysholm score was significantly worse in anterior knee

pain-positive cohort than in anterior knee pain-negative

cohort at 2 years postoperatively. According to logistic

regression analysis, knee extension deficit was a predis-

posing factor for the development of anterior knee pain at

3 months postoperatively (odds ratio, 2.76; P = 0.004);

however, there was no significant predisposing factor for

anterior knee pain at 2 years postoperatively.

Conclusions Knee extension deficit was an important

predisposing factor for postoperative anterior knee pain in

the early postoperative period, and anterior knee pain was

associated with impaired quadriceps function and inferior

subjective results over 2 years postoperatively. Early

recovery of full extension may prevent postoperative

development of anterior knee pain and achieve successful

outcomes for ACL reconstruction.

Level of evidence Retrospective comparative study, Level

III.

Keywords Anterior cruciate ligament � Anterior knee

pain � Risk factors � Logistic regression analysis

Introduction

Anterior cruciate ligament (ACL) reconstruction is cur-

rently one of the most common surgical procedures in

sports medicine and has yielded promising clinical results

for patients with ACL injuries [12]. However, a substantial

number of postoperative complications may occur after

ACL reconstruction, including range of motion (ROM)

deficit, quadriceps weakness, and donor-site morbidity,

particularly after harvesting bone-patellar-tendon-bone

Y. Niki (&) � A. Hakozaki � H. Kanagawa � Y. Toyama �Y. Suda

Department of Orthopaedic Surgery, Keio University,

35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan

e-mail: y.niki@lib.bekkoame.ne.jp

W. Iwamoto � H. Matsumoto

Institute for Integrated Sports Medicine, Keio University, 35,

Shinanomachi, Shinjuku, Tokyo 160-8582, Japan

123

Knee Surg Sports Traumatol Arthrosc (2012) 20:1543–1549

DOI 10.1007/s00167-011-1746-z

(BTB) graft. Donor-site morbidity manifests clinically as

anterior knee pain, donor-site tenderness, pain on kneeling,

and loss of anterior knee sensitivity. Of these, anterior knee

pain is a frequent and important complication with the

potential to impede rehabilitation and return to sports

activity, and lowers functional knee scores such as

Lysholm score [8] and International Knee Documentation

Committee (IKDC) rating scale [17]. Identification of risk

factors for anterior knee pain and methods to reduce the

prevalence of anterior knee pain may thus increase patient

tolerance for rehabilitation and subsequent functional

recovery.

Anterior knee pain has been shown to be multifactorial,

and variables such as postoperative extension deficit [1, 2,

7, 8, 10, 19, 22, 24], flexion deficit [1, 8, 10, 24], gender

[1], age [24], body mass index (BMI), and use of BTB graft

have been identified as factors increasing the risk of post-

operative anterior knee pain. According to the recent sys-

tematic review of randomized controlled trials (RCTs),

among 16 RCTs focusing on anterior knee pain, 7 RCTs

revealed that BTB graft was inferior to the hamstring (HT)

graft in terms of anterior knee pain, whereas 9 RCTs found

an equivalent prevalence of anterior knee pain between

BTB and HT grafts [20], suggesting that etiologies other

than donor-site morbidity might contribute to the devel-

opment of postoperative anterior knee pain. Moreover, one

report revealed that the contribution of donor-site mor-

bidity to postoperative anterior knee pain changed with

time [3]. Given the multifactorial nature of anterior knee

pain development after ACL reconstruction, multivariate

analysis was used to investigate factors affecting anterior

knee pain. The aim of this study was to evaluate the

prevalence of anterior knee pain at 2 time points, 3 months

and 2 years postoperatively, and to identify factors sig-

nificantly influencing anterior knee pain at each time point

using logistic regression analysis. Our hypothesis was that

various factors besides donor-site morbidity would affect

the anterior knee pain development at two different post-

operative intervals, and the donor-site morbidity-related

anterior knee pain would gradually disappear over time.

Materials and methods

Of 191 knees from 186 patients who underwent primary

anatomic double-bundle ACL reconstruction in our insti-

tute between 2006 and 2009, 171 knees (171 patients) were

enrolled in this study. Inclusion criteria were as follows:

C2-year follow-up; no reinjury during the follow-up per-

iod; and full clinical data available from 3 months to

2 years postoperatively, including clinical scores (Tegner

Activity level, Lysholm score, and IKDC evalua-

tion), anteroposterior laxity, and thigh muscle strength.

Exclusion criteria comprised were as follows: previous

ligament reconstruction; multiple ligament injuries; bilat-

eral ACL injuries; and concomitant treatments for articular

cartilage defects, such as osteochondral autologous trans-

plantation and microfracture. Patient characteristics are

shown in detail in Table 1. Regarding graft selection, our

cohort received 71 two double-looped semitendinosus (ST)

grafts, 44 double-looped semitendinosus with double-

looped gracilis (ST-G) grafts, and 56 bone-patellar tendon-

bone graft with double-looped gracilis (BTB-G) grafts.

Uses of the two grafts were allocated based on when the

operation was performed, with BTB-G mainly used

between 2006 and 2007 and HT (i.e., either ST or ST-G)

mainly used between 2007 and 2009. Some small female

patients were considered as contraindicated for BTB-G

reconstruction and underwent HT reconstruction, as the

BTB graft for AMB potentially disturbs bone tunnel cre-

ation for PLB in the small knee. As a result, details of graft

allocation were 51 BTB-G, 5 ST, and 3 ST-G between

2006 and 2007, and 5 BTB-G, 66 ST, and 41 ST-G

between 2007 and 2009.

Surgical techniques

All ACL reconstructions were arthroscopically performed

by a single surgeon using anatomic double-bundle proce-

dures as reported previously [15, 16]. Briefly, BTB graft with

8–9 mm in diameter was used for AMB, and gracilis tendon

folded as a doubled graft was used for PLB in BTB-G

reconstruction. When the BTB graft was harvested, two

mini-incisions were made just above the apex of the patella

and over the tibial tubercle, with the aim of sparing infra-

patellar branch of the saphenous nerve [25]. In HT recon-

struction, 2 double-looped ST tendons were prepared for

both AMB and PLB grafts, when the ST tendon was C24 cm

long. Gracilis tendon was harvested for PLB graft and

Table 1 Demographic characteristics of the study cohort

Number (cases/knees) 171/171

Age, years (range) 29.1 (14–52)

Gender (male/female) 92/79

Follow-up period, years (range) 2.8 (2.0–3.8)

Time from injury to index operation, months (range) 39.2 (1–360)

Preinjury Tegner activity level (range) 5.9 (2–9)

Preoperative Lysholm score 71.7 (35–96)

Type of graft (knees)

BTB-G 56

ST 71

ST-G 44

BTB-G, bone-patellar tendon-bone graft with double-looped gracilis;

ST, two double-looped semitendinosus; ST-G, double-looped semi-

tendinosus with double-looped gracilis

1544 Knee Surg Sports Traumatol Arthrosc (2012) 20:1543–1549

123

double-looped only when the ST tendon was\24 cm long.

Femoral fixations for ST or gracilis tendon grafts were

achieved using EndoButton� CL (Smith & Nephew, Mem-

phis, TN, USA), whereas BTB graft for AMB was fixed using

Endobutton� CL BTB (Smith & Nephew). Tibial graft fix-

ations were achieved using a double spike plate (DSP�;

Meira, Nagoya, Japan) for ST or gracilis tendon grafts, and

with an interference screw (Soft Silk�; Smith & Nephew) for

the BTB graft. Both grafts for AMB and PLB were secured

with 20 N each with the knee in 20� flexion using a ligament

tensioner (Smith & Nephew) to restore relatively normal

tension pattern, as reported previously [14]. This pretension

was employed to all patients, regardless of the graft types.

Evaluation

This study collected and evaluated the data on the presence

and severity of anterior knee pain as well as various clinical

data including clinical scores, anteroposterior laxity and

thigh muscle strength in a retrospective manner. The data

from two different postoperative intervals, 3 months and

2 years after ACL reconstruction, were collected. Anterior

knee pain was diagnosed when a patient undergoing BTB-G

reconstruction presented with soreness at the harvest site or

when a patient undergoing HT reconstruction presented

with soreness and tenderness at the inferior pole of the

patella. Anterior knee pain was commonly reproducible on

single leg squat during clinical assessment in the outpatient

clinic. After dividing patients into two groups based on the

presence or absence of anterior knee pain, univariate anal-

ysis and subsequent multivariate logistic regression analysis

were performed to determine factors significantly affecting

anterior knee pain. The independent variables potentially

associated with anterior knee pain were selected according

to several previous studies focusing on anterior knee pain

after ACL reconstruction [8, 10, 11, 25], which included

age, sex, time from injury to index operation, type of graft

(BTB-G or HT), preinjury Tegner activity level (i.e., ori-

ginal activity level before ACL injury), Tegner activity

level at 2 years postoperatively, anteroposterior knee laxity

measured using a KT-2000� arthrometer (MEDmetric, San

Diego, CA), Lysholm score, IKDC evaluation, knee

extension deficit, knee flexion deficit, and quadriceps

strength. Loss of knee extension and flexion compared with

the non-injured knee was measured with a goniometer and

divided into 3 grades: none, B5�, and 6�–10� for knee

extension deficit, and none, B5�, and 6�–15� for knee

flexion deficit. Particularly, loss of full hyperextension was

registered as having an extension deficit. Isokinetic peak

extension torque at 60�/s was measured using an isokinetic

dynamometer (Biodex Medical Systems, Shirley, NY), for

use as an indicator of quadriceps strength. Regarding test–

retest reliability of the instruments, measurements with

KT-2000� and Biodex dynamometer were carried out by

the same examiner, and the correlation coefficients (r) for

reliability were 0.94 for KT-2000� and 0.90 for Biodex

dynamometer.

Statistical analysis

Statistical analysis was performed using SPSS version 17.0

software (SPSS, Chicago, IL, USA). Student’s t-test was

used to compare continuous valuables between patients

with and without anterior knee pain. Comparison between

the 3 different graft groups was conducted using one-way

analysis of variance (ANOVA) with post hoc testing by the

Boneferroni method. The v2 test and Fisher’s exact test

were used to compare categorical variables between

groups. Multivariate analyses were performed using

logistic regression. Factors found to be associated with

anterior knee pain development at the P \ 0.2 level

according to Student’s t-test or v2 test were included in the

logistic regression analysis. Statistical significance for the

multivariate model was accepted at the P \ 0.05 level.

Results

During the 2-year follow-up period, 1 patient in the BTB-G

group, 5 in the ST group, and 3 in the ST-G group suffered

a traumatic graft rupture, and these 9 patients were

excluded from the analyses. Overall prevalence of anterior

knee pain was 42.0% at 3 months and fell to 11.1% at

2 years postoperatively (Table 2). Similarly, the preva-

lence of severe anterior knee pain classified as stage II or

III markedly decreased during the postoperative 2 years.

Actually, 95% of the patients with anterior knee pain at

2 years postoperatively had also presented with anterior

knee pain at 3 months postoperatively.

Table 2 Prevalence and severity of anterior knee pain at 3 months

and 2 years postoperatively

3 months (n = 162) 2 years (n = 162)

AKP prevalence (%) 42.0 11.1

AKP severitya

Stage I (cases) 25 13

Stage II 33 4

Stage III 10 1

None 94 144

AKP anterior knee paina Severity of AKP was classified into 3 stages: I, pain after activity

only; II, pain during and after activity. Still able to perform at a

satisfactory level, III, pain during and after activity and more pro-

longed. Unable to perform at a satisfactory level

Knee Surg Sports Traumatol Arthrosc (2012) 20:1543–1549 1545

123

The demographic characteristics and clinical data of

patients with anterior knee pain [AKP(?) group] and those

without anterior knee pain [AKP(-) group] at 3 months

and 2 years postoperatively are shown in Table 3.

At 3 months postoperatively, use of BTB-G graft repre-

sented the highest prevalence of anterior knee pain between

the 3 different grafts (P = 0.001). Prevalence of postop-

erative extension deficit was significantly higher in the

AKP(?) group than in the AKP(-) group (P = 0.005,

Table 3). Consequently, use of BTB graft and the presence

of extension deficit following ACL reconstruction were

associated with the development of anterior knee pain in

the early postoperative period. On the other hand, at

2 years postoperatively, the level of quadriceps peak torque

was significantly higher in the AKP(-) group than in the

AKP(?) group (P = 0.004), and Lysholm score was sig-

nificantly lower in the AKP(?) group than in the AKP(-)

group (P = 0.002), indicating that quadriceps strength and

Lysholm score were associated with anterior knee pain at

2 years postoperatively.

Multivariate logistic regression analyses that included

extension deficit and preoperative Lysholm score as

covariates at 3 months postoperatively and time from

injury to operation, P/F cartilage defect, and preinjury

Tegner activity level as covariates at 2 years postopera-

tively were performed to assess predisposing factors for

anterior knee pain at the 2 postoperative time points

(Table 4). The results demonstrated that the presence of

knee extension deficit was significantly associated with

anterior knee pain development at 3 months postopera-

tively (odds ratios: 2.76; P = 0.004), whereas none of the

three candidate variables represented significant associa-

tion with anterior knee pain development at 2 years

postoperatively.

Discussion

The most important finding of the present study was that

multiple factors contributed to anterior knee pain devel-

opment following ACL reconstruction and different factors

acted at different postoperative time periods. Donor-site

morbidity and knee extension deficit were early postoper-

ative problems associated with anterior knee pain, whereas

reduced quadriceps power and inferior subjective outcome

(i.e., Lysholm score) were late problems.

In our case series of ACL reconstruction with BTB-G

grafts, donor-site morbidity after harvesting BTB graft was

associated with anterior knee pain mainly in the early

postoperative phase, as reported by Feller et al. [5].

Although the prevalence of anterior knee pain fell from

61.8% at 3 months to 18.2% at 2 years postoperatively,

high percentage of the patients still presented with anterior

knee pain during sports activities at over 2 years. At pres-

ent, there is little evidence of anterior knee pain following

anatomic double-bundle ACL reconstruction. Zaffagnini

et al. have reported that the prevalence of anterior knee

pain after double-bundle procedure was 20% at 8 years

postoperatively [27], but the femoral bone tunnels were not

in anatomic position. Moreover, considering the data from

a recent systematic review of single-bundle ACL recon-

struction in which prevalence of anterior knee pain aver-

aged 23% at 2 years postoperatively [12], the BTB-G

procedure in this study is considered acceptable for the

prevalence of anterior knee pain.

Numerous authors have stated that loss of extension

causes anterior knee pain [1, 2, 7, 8, 10, 19, 22, 24], and

Shelbourne and Trumper emphasized the importance of

regaining full hyperextension to avoid anterior knee pain

development [22]. In this study, patients who did not regain

full hyperextension as compared to the contralateral side

were registered as having an extension deficit. A retro-

spective view of our case series revealed that 95% of the

patients presenting with anterior knee pain at 2 years

postoperatively had anterior knee pain at 3 months post-

operatively, which may highlight the need for early

recovery of full extension and subsequent prevention of

anterior knee pain development to reduce the final preva-

lence of anterior knee pain. Although previous authors

have reached a consensus on the close relationship between

extension deficit and anterior knee pain after ACL recon-

struction, the underlying mechanisms remain yet to be

elucidated. A recent gait analysis study demonstrated that

knee extension deficit simulated with a knee brace resulted

in increased knee extension moment during walking, which

may yield mechanical overload to quadriceps and sub-

sequent anterior knee pain development [6]. Extension

deficit of the knee, particularly in the early postoperative

stage, reportedly involves a variety of mechanisms,

including arthrofibrosis, fibrous nodule formation just

anterior to the distal part of ACL graft (i.e., cyclops lesion),

excessive pretensioning to the graft, graft fixation with the

knee in flexion, and bone tunnel malpositioning. As double-

bundle ACL reconstruction, which reproduces the pos-

terolateral bundle (PLB) and anteromedial bundle (AMB),

gains in popularity, the latter 3 mechanisms readily allow

the PLB graft to become tightened, resulting in extension

deficit. Moreover, considering increased control of rota-

tional laxity of the double-bundle ACL reconstruction

proven in an experimental cadaver study [4, 13, 26],

excessive tension to the PLB graft may over constrain tibial

rotation and negatively affect the patellofemoral joint,

potentially leading to anterior knee pain. However, in

clinical practice, better control of rotational laxity in the

double-bundle procedure than in the single-bundle proce-

dure remains to be controversial, as recent clinical

1546 Knee Surg Sports Traumatol Arthrosc (2012) 20:1543–1549

123

comparative studies have achieved conflicting results, with

some papers failing to show a difference [9, 18, 21, 23].

Further clinical outcome studies are needed to elucidate the

effects of double-bundle procedures on the tibial rotation,

patellofemoral tracking, and subsequent risk of anterior

knee pain.

Table 3 Comparison of patients with and without anterior knee pain following ACLR

3 months (n = 162) 2 years (n = 162)

AKP ? (n = 68) AKP - (n = 94) P AKP ? (n = 18) AKP - (n = 144) P

Age (years) 30.0 28.2 n.s. 28.4 29.0 n.s.

Gender n.s. n.s.

Male 39 47 9 77

Female 29 47 9 67

Time from injury to

index operation

(months)

42.8 37.5 n.s. 68.9 36.0 n.s.

Type of graft (knees) 0.001* n.s.

BTB-G 34 21 10 45

ST 20 46 5 61

ST-G 14 27 3 38

P/F cartilage defect

[cases (%)]a4 (5.9) 3 (3.2) n.s. 2 (11.1) 5 (3.5) n.s.

Tegner activity

(median)

Preinjury 5 5 n.s. 5 6 n.s.

Postop. ND ND 5 6 n.s.

Anteroposterior laxityb

Mean [mm (SD)] ND ND 0.8 (1.8) 1.0 (1.7) n.s.

B2 mm [knees (%)] 14 (78) 110 (76) n.s.

Lysholm score

Preop. 73.3 70.3 n.s. 70.9 71.6 n.s.

Postop. ND ND 91.6 96.5 0.002*

IKDC n.s.

A (normal) ND ND 8 77

B (nearly normal) ND ND 5 50

C (abnormal) ND ND 5 17

D (severely abnormal) ND ND 0 0

Knee extension deficit

(cases)c0.005* n.s.

None 33 66 16 134

B5� 28 21 1 6

6�–10� 7 7 1 4

Knee flexion deficit

(cases)

n.s. n.s.

None 52 70 15 130

B5� 7 11 2 8

6�–15� 9 13 1 6

Quadriceps torque at

60�/s (% of healthy

side)

ND ND 72.7 81.9 0.004*

Loss of sensitivity (%)d ND ND 43 40 n.s.

ACLR anterior cruciate ligament reconstruction, AKP anterior knee pain, BTB-G, bone-patellar tendon-bone graft with double-looped gracilis; ST, two double-

looped semitendinosus; ST-G, double-looped semitendinosus with double-looped gracilis; P/F patellofemoral, ND not determined, n.s. not significant

* There was statistically significancea Cartilage defect with COuterbridge II was defined as positiveb Side-to-side difference at 134 N torque, as measured by KT-2000c Extension deficit expressed as the difference compared with the contralateral sided Loss of sensitivity was considered positive when the patient complained of any sensory disturbance in the area of the infrapatellar branch of the saphenous nerve

Knee Surg Sports Traumatol Arthrosc (2012) 20:1543–1549 1547

123

Loss of anterior knee sensitivity following ACL recon-

struction has been proposed as an alternative mechanism

underlying anterior knee pain [10, 11]. Several reports have

revealed that intraoperative injuries to the infrapatellar

nerve can cause severe discomfort of the knee, including

anterior knee pain. When any size of sensory loss was

defined as loss of anterior knee sensitivity in our cohort,

approximately 40% of patients displayed loss of sensitivity.

However, this did not influence the prevalence of anterior

knee pain. Moreover, loss of anterior knee sensitivity

reportedly leads to an inability of knee-walking [10, 11],

although the knee-walking test was not performed in the

present study, and we, therefore, cannot shed any light on

this issue. The relatively low frequency of sensitivity loss

in our cohort was attributable to an infrapatellar nerve-

friendly surgical procedure during harvesting of BTB graft.

We used two mini-incisions just above the apex of the

patella and over the tibial tubercle, but not a long longi-

tudinal incision over the central third of the patellar tendon.

Some limitations must be taken into consideration for

this study. First, the relatively small sample size and short

duration of follow-up might obscure precise long-term

clinical outcomes and the fate of anterior knee pain.

As approximately 11% of patients displayed anterior knee

pain at 2 years postoperatively in our cohort, the fate of

anterior knee pain in these patients should be examined

from a long-term perspective. Second, in terms of graft

choice, selection bias may have been present in this study,

as patient allocation to BTB-G or ST or ST-G grafts was

not randomized and was instead based on the time when

the operation was performed. Third, there were inevitable

differences in the method of graft fixation between BTB-G

graft and HT graft. These might influence clinical results of

each graft type, including anterior knee discomfort due to

retained fixation hardware. Fourth, the lack of data on

hamstring muscle strength was one of the drawbacks of this

study, since the degree of donor-site morbidity following

harvest of HT graft as well as BTB graft may have sub-

stantially affected the recovery of muscle function, time to

return to sports, and overall clinical outcomes.

Finally, according to multivariate logistic regression

analysis in this study, postoperative extension deficit was

an important predisposing factor for the development of

anterior knee pain at 3 months postoperatively. Consider-

ing the evidence that most patients presenting with anterior

knee pain at 2 years postoperatively had anterior knee pain

at 3 months postoperatively, full extension equal to the

contralateral knee should be regained within early post-

operative stage, which may prevent chronic anterior knee

pain and subsequent quadriceps weakness and yield satis-

factory clinical results.

Conclusions

The present results indicate that anterior knee pain devel-

opment following ACL reconstruction is multifactorial,

affected by different factors at different postoperative time

periods. Multivariate logistic regression analyses revealed

that knee extension deficit was a significant risk factor for

postoperative anterior knee pain at 3 months postopera-

tively. Continuous anterior knee pain potentially led to

impaired quadriceps function and inferior subjective results

over 2 years postoperatively.

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Table 4 Multivariate logistic regression analysis of risk factors for

anterior knee pain following ACLR

Risk factors for AKP OR 95% CI P

3 months after ACLR

Extension deficit (3 months) 2.76 1.37–5.54 0.004*

Lysholm score (preop.) 1.02 0.99–1.05 n.s.

2 years after ACLR

Time from injury to operation 1.003 0.99–1.01 n.s.

P/F cartilage defect 1.12 0.11–10.9 n.s.

Tegner activity (preinjury) 0.85 0.59–1.21 n.s.

ACLR anterior cruciate ligament reconstruction, AKP anterior knee

pain, OR odds ratio, CI confidence interval, preop. preoperative, P/

F patellofemoral, n.s. not significant

* There was statistical significance

1548 Knee Surg Sports Traumatol Arthrosc (2012) 20:1543–1549

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