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Pawan Kumar KM, Mundargi A, Puttamaregowda M, Kammagondanahalli RK, Perumalswamy S, Shantharam SM. LFCI and knee morphological parameters as a risk factor in anterior cruciate ligament tear on magnetic resonance imaging- A case control analysis. J Clin Orthop Trauma 2024; 55:102514. [PMID: 39247087 PMCID: PMC11377136 DOI: 10.1016/j.jcot.2024.102514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/01/2024] [Accepted: 08/12/2024] [Indexed: 09/10/2024] Open
Abstract
Background The anterior cruciate ligament is commonly injured and multiple risk factors have been studied. But there is paucity of articles considering predictive risk factors of femoral condyle morphology in south Indian population. This study aims to assess distal femoral condyle sphericity as a risk factor in anterior cruciate ligament injury and to correlate it with proximal tibia morphological risk factors. Materials and methods This is a case control study including 80 patients with knee MRI aged between 18 and 60.They were grouped into cases (40) and controls (40). Cases being non-contact ACL injuries without multi ligamentous injuries and controls being MRI with ACL intact. Lateral femoral condyle index, posterior tibial slope, medial and lateral tibial depth were measured and compared. The risk factors were analysed with multiple logistic regression. Results The lateral femoral condyle index had a mean value of 0.79 with standard deviation of ± 0.05 in cases group. Control group had a mean value of 0.803 with standard deviation of ± 0.05. Medial tibial slope in cases (8°) was lesser than in control group (7.6°). Lateral tibial slope was found to more among cases group (9.1°) than in control group (7.5°). Medial tibial depth had a mean of 4.07 mm among cases and 3.9 mm among control group. There was a moderate positive correlation between LFCI and Medial Tibial slope among cases that was statistically significant (P = 0.002). In addition, there was a weak negative correlation between LCFI and Medial Tibial Depth that was statistically significant. Conclusion The lateral femoral condyle index was not found to be significant statistically among ACL injured patients. In our study we concluded that lateral tibial slope was more reliable risk factor in predicting ACL injury when compared to other parameters.
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Affiliation(s)
- Keelara Mahadevappa Pawan Kumar
- Department of Orthopaedics, DSU-Dayananda Sagar University, CDSIMER (Chandramma Dayananda Sagar Institute of Medical Education & Research), Bangalore, Karnataka, India
| | | | | | | | | | - Shetty M Shantharam
- Shantharam Shetty Institute of Orthopaedics and Traumatology, Department of Orthopaedics, Karnataka, India
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Huart J, Pozzi A, Bleedorn J, Lu TW, Knell S, Park B. Statistical shape modeling of the geometric morphology of the canine femur, tibia, and patella. Front Vet Sci 2024; 11:1366827. [PMID: 39051009 PMCID: PMC11266300 DOI: 10.3389/fvets.2024.1366827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 06/11/2024] [Indexed: 07/27/2024] Open
Abstract
Bone morphometry varies among dogs of different sizes and breeds. Studying these differences may help understand the predisposition of certain breeds for specific orthopedic pathologies. This study aimed to develop a statistical shape model (SSM) of the femur, patella, and tibia of dogs without any clinical orthopeadic abnormalities to analyze and compare morphological variations based on body weight and breed. A total of 97 CT scans were collected from different facilities and divided based on breed and body weight. The 3D models of the bones were obtained and aligned to a coordinate system. The SSM was created using principal component analysis (PCA) to analyze shape variations. The study found that the first few modes of variation accounted for a significant percentage of the total variation, with size/scale being the most prominent factor. The results provide valuable insights into normal anatomical variations and can be used for future research in understanding pathological bone morphologies and developing 3D imaging algorithms in veterinary medicine.
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Affiliation(s)
- Jeremy Huart
- Clinic for Small Animal Surgery, Department for Small Animals, Vetsuisse Faculty University of Zurich, Zürich, Switzerland
| | - Antonio Pozzi
- Clinic for Small Animal Surgery, Department for Small Animals, Vetsuisse Faculty University of Zurich, Zürich, Switzerland
| | - Jason Bleedorn
- Department of Veterinary Clinical Sciences, Colorado State University, Fort Collins, CO, United States
| | - Tung-Wu Lu
- Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - Sebastian Knell
- Clinic for Small Animal Surgery, Department for Small Animals, Vetsuisse Faculty University of Zurich, Zürich, Switzerland
| | - Brian Park
- Clinic for Small Animal Surgery, Department for Small Animals, Vetsuisse Faculty University of Zurich, Zürich, Switzerland
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Gao YT, Yang YP, Meng QY, Chen NY, Ma Y, Liu P, Wang C, Shi WL. Increased Lateral Femoral Condyle Ratio Measured by Magnetic Resonance Imaging Is Associated With Anterior Cruciate Ligament Rerupture. Arthroscopy 2024; 40:1557-1565. [PMID: 37813203 DOI: 10.1016/j.arthro.2023.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/08/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
PURPOSE To investigate the association between lateral femoral condyle ratio (LFCR) measured by magnetic resonance imaging (MRI) and anterior cruciate ligament (ACL) rerupture after anatomic ACL reconstruction (ACLR) and to compare the diagnostic accuracy between MRI and radiograph measurements. METHODS A retrospective review was conducted on patients who underwent anatomic ACLR in our institution between 2015 and 2018. Patients who experienced rerupture after ACLR were identified and matched 1:1 with control patients who showed no evidence of graft failure during a minimum 48-month follow-up. The matching criteria included age, sex, and body mass index. LFCR was measured on MRI scans and radiographs of the affected limb. Patients' characteristics, surgical features, and anatomic measurements were compared between groups. Conditional logistic regression was performed to investigate whether MRI-measured LFCR is a risk factor for ACL rerupture. The optimal cutoff value was determined by receiver operating characteristic curves (ROC). Delong's test was performed to compare the diagnostic accuracy between MRI and radiograph measurements. RESULTS A total of 72 patients who sustained ACL rerupture were included and matched with 72 control subjects. Compared to patients with intact ACLR, those who sustained ACL rerupture showed a significant increase in LFCR on MRI scans (63.38% ± 2.26% [95% CI, 62.84%-63.91%] vs 61.10% ± 2.19% [95% CI, 60.59%-61.61%], P < .001). An MRI-measured LFCR >62.18% was set as the cutoff point to discern patients at a higher risk of graft failure after anatomic ACLR, with sensitivity and specificity of 75.0% and 70.8%, respectively. MRI-measured LFCR demonstrated superior diagnostic accuracy during ROC curve analysis, achieving a higher area under the curve compared to radiograph-measured LFCR (0.783 ± 0.051 vs 0.668 ± 0.060, P = .041). CONCLUSIONS The study found that MRI-measured LFCR was associated with ACL rerupture. A cutoff value of 62.18% was determined, which can help identify patients at a higher risk of rerupture. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Yi-Tian Gao
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Yu-Ping Yang
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Qing-Yang Meng
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Na-Yun Chen
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Yong Ma
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Ping Liu
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Cheng Wang
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Wei-Li Shi
- Institute of Sports Medicine, Peking University Third Hospital No. 49, Beijing, China.
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Sun Y, Tang Y. The relationship between lateral femoral condyle ratio measured by MRI and anterior cruciate ligament injury. Front Bioeng Biotechnol 2024; 12:1362110. [PMID: 38600950 PMCID: PMC11004325 DOI: 10.3389/fbioe.2024.1362110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/18/2024] [Indexed: 04/12/2024] Open
Abstract
Background Previous studies have shown that the lateral femoral condyle ratio (LFCR) measured by X-ray has a significant relationship with the anterior cruciate ligament (ACL) injury. However, few relevant studies have been performed on LFCR measured by magnetic resonance imaging (MRI). Purpose (1) To evaluate the relationship between LFCR measured by MRI and ACL injury or rerupture. (2) To compare the LFCR measured by MRI with existing bony morphological risk factors and screen out the most predictive risk factors for primary ACL injury or rerupture. Study Design Cohort study; Level of evidence, 3. Methods Totally 147 patients who underwent knee arthroscopic surgery from 2015 to 2019 with minimum follow-up of 48 months were retrospectively evaluated. Patients were placed into three groups: 1) the control group of patients with simple meniscus tears without ligament injury; 2) the primary noncontact ACL injury group; 3) ACL rerupture group (ACL reconstruction failure). The LFCR measured by MRI and other previous known risk factors associated with MRI (notch width index, medial tibial slope, lateral tibial slope, medial tibial depth, lateral tibial height) were performed to evaluate their predictive value for ACL injury and rerupture. All the risk factors with p < 0.01 according to univariate analysis were included in the logistic regression models. Receiver operating characteristic (ROC) curves were analyzed for sensitivity, specificity, cut-off, and area under the curve (AUC). Z tests were used to compare the AUC values. Results The LFCR measured by MRI was obviously higher in primary ACL injury group (0.628 ± 0.020) and in ACL rerupture group (0.625 ± 0.021) than that in the control group (0.593 ± 0.030). The best risk factor was the LFCR with a cut-off of 0.602 (AUC, 0.818; 95% CI, 0.748-0.878; sensitivity, 90%; specificity, 66%). When combined with lateral tibial slope (cutoff, 7°) and lateral tibial height (cutoff, 3.6 mm), the diagnostic performance was improved significantly (AUC, 0.896; 95% CI, 0.890-0.950; sensitivity, 87%; specificity, 80%). Conclusion The increased LFCR measured by MRI was associated with a significantly higher risk for ACL injury or rerupture. The combination of LFCR, lateral tibial slope and lateral tibial height were the most predictive risk factors. This may help clinicians identify susceptible individuals and allow precision approaches for better prevention, treatment and management of this disease.
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Affiliation(s)
- Yang Sun
- Department of Sports Medicine, The First People’s Hospital of Lianyungang, Lianyungang, China
| | - Yun Tang
- Department of Sports Medicine, The First People’s Hospital of Lianyungang, Lianyungang, China
- Clinical Research Center, The First People’s Hospital of Lianyungang, Lianyungang, China
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Yang L, Xing S. Increased lateral femoral condyle ratio measured by MRI is associated with higher risk of solitary meniscus injury. Front Bioeng Biotechnol 2024; 12:1286967. [PMID: 38380265 PMCID: PMC10877371 DOI: 10.3389/fbioe.2024.1286967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/09/2024] [Indexed: 02/22/2024] Open
Abstract
Background: Past studies found that an increased lateral femoral condyle ratio is associated with anterior cruciate ligament injuries, but it is not clear if there is a link between MRI-measured lateral femoral condyle ratios and meniscal injuries. MRI provides a more accurate selection of measurement planes. Compared to X-rays, it further reduces data errors due to non-standard positions. Objective: To study the relationship between knee bone morphology and Solitary meniscal injuries by MRI. Methods: A total of 175 patients were included in this retrospective case-control study, including 54 cases of pure medial meniscus injury, 44 cases of pure lateral meniscus injury as the experimental group, and 77 control subjects. MRI images were used to measure the femoral notch width, femoral condylar width, femoral notch width index, lateral femoral condylar ratio (LFCR), posterior tibial slope, medial tibial plateau depth, and meniscus slope. In addition, carefully check for the presence of specific signs such as bone contusions and meniscal extrusions. Comparing the anatomical differences in multiple bone morphologies between the two groups, a stepwise forward multifactorial logistic analysis was used to identify the risk factors for Solitary meniscal injuries. Finally, ROC curves were used to determine the critical values and best predictors of risk factors. Results: MTS, LTS, and LFCR ended up as independent risk factors for meniscus injury. Among all risk factors, LFCR had the largest AUC of 0.781 (0.714-0.848) with a threshold of 72.75%. When combined with MTS (>3.63°), diagnostic performance improved with an AUC of 0.833 (0.774-0.892). Conclusion: Steep medial tibial plateau slope, steep lateral tibial plateau slope angle, and deep posterior lateral femoral condyles on MRI are independent risk factors for meniscal injuries. In patients with knee discomfort with the above imaging findings (X-ray, MRI), we should suspect and carefully evaluate the occurrence of meniscal injuries. It not only provides a theoretical basis to understand the mechanism of meniscus injury but also provides theoretical guidance for the prevention of meniscus injury and the development of intervention measures. Level of evidence III.
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Affiliation(s)
- Lei Yang
- Department of North Sichuan Medical College, Nanchong, Sichuan, China
- Department of Orthopedics, Chengdu Fifth People’s Hospital, Chengdu, Sichuan, China
| | - Shuxing Xing
- Department of Orthopedics, Chengdu Fifth People’s Hospital, Chengdu, Sichuan, China
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Chen J, Wu X, Guo J, Zhang X, Zhao J, Xie G. Characterization of the CT-based risk factors for concomitant patellofemoral instability in patients with anterior cruciate ligament injury. Eur Radiol 2024; 34:250-259. [PMID: 37532901 DOI: 10.1007/s00330-023-10028-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/22/2023] [Accepted: 06/14/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVES Underestimation of concomitant patellofemoral instability in patients with anterior cruciate ligament (ACL) injury has aroused extensive attention. However, the characteristics of the combined injury is not well recognized. Hence, we aimed to characterize the features of the combined injury, and determine the radiographic risk factors. METHODS Fifteen radiological parameters were identified after discussion and pilot-tested. Radiographic measurements were compared using the analysis of variance model with Tukey post hoc analysis. A stepwise binomial logistic regression was performed and a nomogram model combining the significant risk factors was created. The model performance was validated by C-index, calibration plot, and decision curve. RESULTS A total of 204 patients (mean [SD] age, 25.1 [6.7] years; 108 [52.9%] male) were included. The final model was updated through regression analysis using 4 parameters as significant risk factors: lateral femoral condyle ratio (OR (95% CI), 1.194 (1.023 to 1.409)), medial anterior tibial subluxation (mATS) (OR (95% CI), 1.234 (1.065 to 1.446)), medial posterior plateau tibial angle (mPPTA) (OR (95% CI), 1.266 (1.088 to 1.500)), and trochlear depth (OR (95% CI), 0.569 (0.397 to 0.784)). C-index for the nomogram was 0.802 (95% CI, 0.731 to 0.873) and was confirmed to be 0.784 through bootstrapping validation. Calibration plot established a good agreement between prediction and observation. Decision curve analysis showed that if threshold probability was over 10%, using the nomogram adds more benefit than either all or none scheme. CONCLUSIONS Lateral femoral condyle ratio, mATS, mPPTA, and trochlear depth are strong adverse predictors of patellofemoral instability in patients with ACL injury. CLINICAL RELEVANCE This study characterizes the radiological features of the combined injury. Patellofemoral instability should be noted when treating ACL injuries. KEY POINTS • The radiological characteristics of the combined ACL injury and patellofemoral instability is not well recognized. • Lateral femoral condyle ratio, mATS, mPPTA, and trochlear depth are predominant risk factors for patellofemoral instability in patients with ACL injury. • Patellofemoral instability should be noted when treating ACL injuries.
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Affiliation(s)
- Jiebo Chen
- Department of Sports Medicine, National Clinical Medical Centre of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
| | - Xiulin Wu
- Department of Sports Medicine, National Clinical Medical Centre of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
| | - Jingyi Guo
- Clinical Research Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
| | - Xueying Zhang
- Department of Sports Medicine, National Clinical Medical Centre of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
| | - Jinzhong Zhao
- Department of Sports Medicine, National Clinical Medical Centre of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China.
| | - Guoming Xie
- Department of Sports Medicine, National Clinical Medical Centre of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China.
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Dadoo S, Ozbek EA, Nukuto K, Runer A, Keeling LE, Grandberg C, Kuroda R, Zaffagnini S, Karlsson J, Hughes JD, Irrgang JJ, Musahl V. What it takes to have a high-grade pivot shift-focus on bony morphology. Knee Surg Sports Traumatol Arthrosc 2023; 31:4080-4089. [PMID: 37410122 DOI: 10.1007/s00167-023-07472-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 05/30/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE Variations in femoral and tibial bony morphology have been associated with higher clinical grading and increased quantitative tibial translation, but not tibial acceleration, during the pivot shift test following anterior cruciate ligament (ACL) injury. The purpose of this study was to determine the impact of femoral and tibial bony morphology, including a measurement influenced by both parameters (the Lateral Tibiofemoral Articular Distance (LTAD)), on the degree of quantitative tibial acceleration during the pivot shift test and rates of future ACL injury. METHODS All patients who underwent primary ACL reconstruction from 2014 to 2019 by a senior orthopedic surgeon with available quantitative tibial acceleration data were retrospectively reviewed. All patients underwent a pivot shift examination under anesthesia with a triaxial accelerometer. Measurements of femoral and tibial bony morphology were performed by two fellowship-trained orthopedic surgeons using preoperative magnetic resonance imaging and lateral radiographs. RESULTS Fifty-one patients were included at a mean follow-up of 4.4 years. The mean quantitative tibial acceleration during the pivot shift was 13.8 m/s2 (range: 4.9-52.0 m/s2). A larger Posterior Condylar Offset Ratio (r = 0.30, p = 0.045), smaller medial-to-lateral width of the medial tibial plateau (r = - 0.29, p = 0.041), lateral tibial plateau (r = - 0.28, p = 0.042), and lateral femoral condyle (r = - 0.29, p = 0.037), and a decreased LTAD (r = - 0.53, p < 0.001) significantly correlated with increased tibial acceleration during the pivot shift. Linear regression analysis demonstrated an increase in tibial acceleration of 1.24 m/s2 for every 1 mm decrease in LTAD. Nine patients (17.6%) sustained ipsilateral graft rupture and 10 patients (19.6%) sustained contralateral ACL rupture. No morphologic measurements were associated with rates of future ACL injury. CONCLUSION Increased convexity and smaller bony morphology of the lateral femur and tibia were significantly associated with increased tibial acceleration during the pivot shift. Additionally, a measurement, termed the LTAD, was found to have the strongest association with increased tibial acceleration. Based on the results of this study, surgeons can utilize these measurements to preoperatively identify patients at risk of increased rotatory knee instability. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Sahil Dadoo
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Emre Anil Ozbek
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Orthopedic Surgery and Traumatology, University of Ankara, Ankara, Turkey
| | - Koji Nukuto
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Armin Runer
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Laura E Keeling
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Camila Grandberg
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica, Istituto Orthopedico Rizzoli, Bologna, Italy
| | - Jon Karlsson
- Department for Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jonathan D Hughes
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department for Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - James J Irrgang
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Volker Musahl
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department for Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Pfeiffer TR. Editorial Commentary: Bony Morphology Determines the Extent of Concomitant Injuries in Anterior Cruciate Ligament Injured Knees. Arthroscopy 2023; 39:1242-1243. [PMID: 37019536 DOI: 10.1016/j.arthro.2022.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 12/22/2022] [Indexed: 04/07/2023]
Abstract
The bony morphology of both tibia and femur has been found to influence the risk of anterior cruciate ligament (ACL) injuries. Quantifying the femoral condylar's sagittal morphology, the lateral femoral condyle ratio (LFCR) has been associated with injuries to the anterolateral knee joint capsule, including the anterolateral ligament in ACL-injured knees. Rotational instability may be in part attributable to femoral anisometry with an increase of the LFCR contributing to increased laxity and risk for ACL ruptures as well as concomitant injuries. While there is currently no surgical treatment available to change the bony morphology of the femur, possibilities such as the addition of a lateral extra-articular tenodesis, adjustment of graft selection, or modification of surgical techniques may mitigate the risk of ACL rerupture in patients with a high LFCR.
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Zheng T, Song G, Wang C, Li Y, Zhang Z, Cao Y, Feng Z, Di M, Zhang H. Effect of Anterolateral Ligament Status and Inherent Knee Anatomy on Anterior Tibial Subluxation of the Lateral Compartment After Acute Anterior Cruciate Ligament Injury: A Cohort Study Based on MRI Analysis. Am J Sports Med 2023; 51:968-976. [PMID: 36779576 DOI: 10.1177/03635465231151694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
BACKGROUND Anterior tibial subluxation (ATS) of the lateral compartment entails a pathological tibiofemoral alignment in knees with anterior cruciate ligament (ACL) injury. Causes of increased ATS after an acute ACL injury are not clear, but soft tissue abnormalities and bony variations of the knee are potential causes. PURPOSE To determine whether increased ATS of the lateral compartment in knees with acute ACL injury is associated with (1) anterolateral ligament (ALL) status and (2) inherent anatomy of the lateral femoral condyle (LFC) and lateral tibial plateau (LTP). STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A total of 337 patients with clinically diagnosed ACL injuries treated between September 2019 and August 2021 were retrospectively reviewed, and 119 patients with acute ACL injury were included. Of them, 79 patients with impaired ALL (ALL injury group) and 40 patients with intact ALL (ALL intact group) were identified based on magnetic resonance imaging (MRI). The ATS of the lateral compartment measured on MRI was compared between the 2 groups. The bony anatomy of knees, quantified by the LFC length, LFC height, LTP length, and LTP slope, was also evaluated on MRI and correlated with the ATS with partial correlation coefficients. Multivariate linear regression was used to identify the independent predictors of increased ATS. RESULTS The ATS of the lateral compartment in the ALL injury group was significantly larger than that in the ALL intact group (6.3 mm vs 4.0 mm, respectively; P = .001). In all included patients, the presence of ALL injuries independently predicted a mean increase in ATS of 1.8 mm (P = .003). In the ALL injury group, ATS was significantly correlated with LFC length (r = 0.463; P < .001), LFC height (r = -0.415; P < .001), and LTP slope (r = 0.453; P < .001); further, a 1-mm increase in LFC length, 1-mm decrease in LFC height, and 1° increase in LTP slope independently predicted a mean increase in ATS of 0.7 mm (P < .001), 0.6 mm (P < .001), and 0.5 mm (P < .001), respectively. In the ALL intact group, there was no significant correlation between ATS and any bony parameter. CONCLUSION An impaired ALL increased the ATS of the lateral compartment after acute ACL injuries. In patients with combined ALL injuries, a flatter LFC and a steeper LTP in the sagittal plane were predictors of a further increase in ATS.
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Affiliation(s)
- Tong Zheng
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Guanyang Song
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Chao Wang
- Department of Epidemiology and Biostatistics, Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Beijing, China
| | - Yue Li
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Zhijun Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Yanwei Cao
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Zheng Feng
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Menglinqian Di
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Hui Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
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Godshaw BM, Hughes JD, Lucidi GA, Setliff J, Sansone M, Karlsson J, Musahl V. Posterior tibial plateau impaction fractures are not associated with increased knee instability: a quantitative pivot shift analysis. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07312-3. [PMID: 36633602 DOI: 10.1007/s00167-023-07312-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/03/2023] [Indexed: 01/13/2023]
Abstract
PURPOSE This study aimed to evaluate posterolateral tibial plateau impaction fractures and how they contribute to rotatory knee laxity using quantitative pivot shift analysis. It was hypothesised that neither the presence of nor the degree of involvement of the plateau would affect rotatory knee laxity in the ACL-deficient knee. METHODS A retrospective review of prospectively collected data on 284 patients with complete anterior cruciate ligament (ACL) injuries was conducted. Posterolateral tibial plateau impaction fractures were identified on preoperative MRI. The patients were divided into two cohorts: "fractures" or "no fractures". The cohort with fractures was further categorised based on fracture morphology: "extra-articular", "articular-impaction", or "displaced-articular fragment". All data were collected during examination under anaesthesia performed immediately prior to ACL reconstruction. This included a standard pivot shift test graded by the examiner and quantitative data including anterior tibial translation (mm) via Rolimeter, quantitative pivot shift (QPS) examination (mm) via PIVOT tablet technology, and acceleration (m/sec2) during the pivot shift test via accelerometer. Quantitative examinations were compared with the contralateral knee. RESULTS There were 112 patients with posterolateral tibial plateau impaction fractures (112/284, 39%). Of these, 71/112 (63%) were "extra-articular", 28/112 (25%) "articular-impaction", and 13/112 (12%) "displaced-articular". Regarding the two groups with or without fractures, there was no difference in subjective pivot shift (2 ± 0 vs 2 ± 0, respectively, n.s.), QPS (2.4 ± 1.6 mm vs 2.7 ± 2.2 mm, respectively, n.s.), anterior tibial translation measurements (6 ± 3 mm vs 5 ± 3 mm, respectively, n.s.), or acceleration of the knee during the pivot (1.7 ± 2.3 m/s2 vs 1.8 ± 3.1 m/s2, respectively, n.s.). When the fractures were further subdivided, subgroup analysis revealed no significant differences noted in any of the measured examinations between the fracture subtypes. CONCLUSION This study showed that the posterolateral tibial plateau impaction fractures are commonly encountered in the setting of ACL tears; however, contrary to previous reports, they do not significantly increase rotatory knee laxity. This suggests that this type of concomitant injury may not need to be addressed at the time of ACL reconstruction. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Brian M Godshaw
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Rooney Sports Complex, 3200 South Water Street, Pittsburgh, PA, 15203, USA
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Rooney Sports Complex, 3200 South Water Street, Pittsburgh, PA, 15203, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gian Andrea Lucidi
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Rooney Sports Complex, 3200 South Water Street, Pittsburgh, PA, 15203, USA
| | - Joshua Setliff
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Rooney Sports Complex, 3200 South Water Street, Pittsburgh, PA, 15203, USA
| | - Mikael Sansone
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jon Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Rooney Sports Complex, 3200 South Water Street, Pittsburgh, PA, 15203, USA.
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11
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Park YB, Kim H, Lee HJ, Baek SH, Kwak IY, Kim SH. The Clinical Application of Machine Learning Models for Risk Analysis of Ramp Lesions in Anterior Cruciate Ligament Injuries. Am J Sports Med 2023; 51:107-118. [PMID: 36412925 DOI: 10.1177/03635465221137875] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Peripheral tears of the posterior horn of the medial meniscus, known as "ramp lesions," are commonly found in anterior cruciate ligament (ACL)-deficient knees but are frequently missed on routine evaluation. PURPOSE To predict the presence of ramp lesions in ACL-deficient knees using machine learning methods with associated risk factors. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 2. METHODS This study included 362 patients who underwent ACL reconstruction between June 2010 and March 2019. The exclusion criteria were combined fractures and multiple ligament injuries, except for medial collateral ligament injuries. Patients were grouped according to the presence of ramp lesions on arthroscopic surgery. Binary logistic regression was used to analyze risk factors including age, sex, body mass index, time from injury to surgery (≥3 or <3 months), mechanism of injury (contact or noncontact), side-to-side laxity, pivot-shift grade, medial and lateral tibial/meniscal slope, location of bone contusion, mechanical axis angle, and lateral femoral condyle (LFC) ratio. The receiver operating characteristic curve and area under the curve were also evaluated. RESULTS Ramp lesions were identified in 112 patients (30.9%). The risk for ramp lesions increased with steeper medial tibial and meniscal slopes, higher knee laxity, and an increased LFC ratio. Comparing the final performance of all models, the random forest model yielded the best performance (area under the curve: 0.944), although there were no significant differences among the models (P > .05). The cut-off values for the presence of ramp lesions on receiver operating characteristic analysis were as follows: medial tibial slope >5.5° (P < .001), medial meniscal slope >5.0° (P < .001), and LFC ratio >71.3% (P = .033). CONCLUSION Steep medial tibial and meniscal slopes, an increased LFC ratio, and higher knee rotatory laxity were observed risk factors for ramp lesions in patients with an ACL injury. The prediction model of this study could be used as a supplementary diagnostic tool for ramp lesions in ACL-injured knees. In general, care should be taken in patients with ramp lesions and its risk factors during ACL reconstruction.
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Affiliation(s)
- Yong-Beom Park
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Hyojoon Kim
- Department of Computer Science, Princeton University, Princeton, New Jersey, USA
| | - Han-Jun Lee
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Suk-Ho Baek
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Il-Youp Kwak
- Department of Applied Statistics, Chung-Ang University, Seoul, Republic of Korea
| | - Seong Hwan Kim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Seoul, Republic of Korea
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12
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Hamdan M, Haddad B, Alshrouf MA, Azzam MI, Isleem U, Hamasha R, Albtoush OM, Alhusban MT, Mubarak N, Alryalat SA. Can MRI knee joint measurements predict the population at risk of ACL injury? BMC Sports Sci Med Rehabil 2022; 14:98. [PMID: 35655282 PMCID: PMC9161517 DOI: 10.1186/s13102-022-00495-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/31/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) injuries have been increasing significantly over time. The relationship between the ACL injury and the knee joint structures is poorly understood. The purpose of this study is to examine whether the measurements of different structures in the knee joint are linked with ACL injury in affected patients. METHODS This retrospective case-control study included patients who suffered from ACL tears and underwent magnetic resonance imaging (MRI). A control group of patients with no knee pathologies on MRI was included. Fourteen knee variables, including lateral meniscus (LM) posterior horn height, length, depth, and volume; medial meniscus (MM) posterior horn height, length, depth, and volume; lateral and medial (MFC) femoral condyle sphere diameter; lateral and medial tibial plateau length; and patella tendon horizontal and vertical diameter, were collected. A multivariate logistic regression including LM posterior horn depth, MM posterior horn length, MM volume, MFC sphere diameter, and patella tendon horizontal diameter and receiver operating characteristic curve, was used to compare the two groups. RESULTS A total of 85 patients were included in our study; 54 suffered from ACL injuries and 31 as a control group with normal knee MRI. Logistic regression revealed that increased LM posterior horn depth (OR = 1.27; 95% CI = 1.03-1.56; p = 0.028), decreased MM posterior horn length (OR = 0.71; 95% CI = 0.55-0.93; p = 0.013), and MFC sphere diameter (OR = 1.20; 95% CI = 1.01-1.43; p = 0.035) were independent risk factors for ACL rupture. The MFC sphere diameter yielded the highest area under the curve: 0.747 (95% CI, 0.632-0.862). No difference was found in the other measurements between the two groups. CONCLUSIONS Concerning the difference in anatomical variations, the lateral meniscus posterior horn depth and medial femoral condyle sphere diameter were higher, while medial meniscus posterior horn length was lower in patients with an ACL injury. These structural knee measurements could have a possible increase in the likelihood of sustaining an ACL injury and can be used by clinicians to predict ACL injury.
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Affiliation(s)
- Mohammad Hamdan
- Division of Orthopaedics, Department of Special Surgery, School of Medicine, The University of Jordan, Amman, Jordan
| | - Bassem Haddad
- Division of Orthopaedics, Department of Special Surgery, School of Medicine, The University of Jordan, Amman, Jordan
| | - Mohammad Ali Alshrouf
- The School of Medicine, The University of Jordan, Queen Rania Street, Amman, 11942, Jordan.
| | - Muayad I Azzam
- The School of Medicine, The University of Jordan, Queen Rania Street, Amman, 11942, Jordan
| | - Ula Isleem
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Reem Hamasha
- The School of Medicine, The University of Jordan, Queen Rania Street, Amman, 11942, Jordan
| | - Omar M Albtoush
- Department of Radiology, University of Jordan, Amman, Jordan
| | - Muna Tayel Alhusban
- The School of Medicine, The University of Jordan, Queen Rania Street, Amman, 11942, Jordan
| | - Nidaa Mubarak
- Department of Radiology, University of Jordan, Amman, Jordan
| | - Saif Aldeen Alryalat
- Department of Special Surgery, Division of Ophthalmology, The University of Jordan, Amman, Jordan
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13
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Jeon N, Choi NH, Hwangbo BH, Victoroff BN. An Increased Lateral Femoral Condyle Ratio in Addition to Increased Posterior Tibial Slope and Narrower Notch Index Is a Risk Factor for Female Anterior Cruciate Ligament Injury. Arthroscopy 2022; 38:1597-1604. [PMID: 34710572 DOI: 10.1016/j.arthro.2021.10.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/08/2021] [Accepted: 10/20/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the relationship between the lateral femoral condyle ratio (LFCR) among osseous morphologic characteristics of the knee and anterior cruciate ligament (ACL) injury in female patients. METHODS Inclusion criteria were female patients (ACL group, n = 59) undergoing primary ACL reconstruction from 2012 to 2018. Control female patients (control group, n = 58) were matched by age, height, and body mass index to ACL group. They had no meniscal or ligament tear, and no trochlear dysplasia on magnetic resonance imaging. The LFCR, notch width index (NWI), and posterior tibial slope (PTS) were measured and compared between the ACL and control groups. For each risk factor, the receiver operating characteristic curve and the area under the curve and its 95% confidence interval (CI) was calculated to determine the cutoff for detecting increased risk of ACL injury. RESULTS The LFCR was significantly larger in the knees in the ACL group than in the control group (P = .001). The NWI was significantly smaller and the PTS was significantly larger in the knees in the ACL group than in the control group (P = .000, P = .000, respectively). The NWI (odds ratio [OR] 1.41; P = .000) was the most significant factor, followed by the PTS (OR 1.29; P = .003) and the LFCR (OR 1.26; P = .001). The area under the curve (0.67, 95% CI 0.58-0.77) for the LFCR had a sensitivity of 66% and specificity of 66% to predict an ACL injury. The cutoff of 63.9 was associated with an increased risk for ACL injury (OR 3.71; 95% CI 1.73-7.95). CONCLUSIONS An increased LFCR was associated with female ACL injury. The LFCR, NWI, and PTS are predictive risk factors for an ACL injury. These findings need to be considered for clinician in identifying female patients at risk for an ACL injury. LEVEL OF EVIDENCE III, retrospective comparative prognostic trial.
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Affiliation(s)
- Neunghan Jeon
- Department of Orthopedic Surgery, Eulji Medical Center, Seoul, South Korea
| | - Nam-Hong Choi
- Department of Orthopedic Surgery, Eulji Medical Center, Seoul, South Korea.
| | - Byung-Hun Hwangbo
- Department of Orthopedic Surgery, Eulji Medical Center, Seoul, South Korea
| | - Brian N Victoroff
- Department of Orthopedic Surgery, Case Western Reserve University, Cleveland, Ohio, U.S.A
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14
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He M, Li J. Increased lateral femoral condyle ratio measured by MRI is associated with higher risk of noncontact anterior cruciate ligament injury. BMC Musculoskelet Disord 2022; 23:190. [PMID: 35232401 PMCID: PMC8886831 DOI: 10.1186/s12891-022-05134-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Studies have shown a significant association between the radiographically measured lateral femoral condyle ratio (LFCR) and anterior cruciate ligament (ACL) injury. However, it is unclear whether LFCR measured by magnetic resonance imaging (MRI) is associated with a higher risk of noncontact ACL injury. OBJECTIVE To investigate the effect of LFCR on the risk of noncontact ACL injury by MRI. 2 to investigate the association of LFCR measured by MRI with multiple bone morphological risk factors and evaluate the most sensitive risk predictors of noncontact ACL injury. METHODS A total of 116 patients, including 58 subjects with noncontact ACL injury and 58 age-matched and sex-matched controls with only meniscus injury, were included in this retrospective case-control study. LFCR, lateral tibial slope (LTS), lateral tibial height (LTH), medial tibial slope (MTS), and medial tibial depth (MTD) were measured on MRI. The differences in each index between the two groups were compared, and risk factors were screened by single-factor logistic regression analysis. Indicators with P values < 0.1 were included in the logistic regression equation. The critical values and areas under the curve (AUCs) of independent risk factors were determined by receiver operating characteristic (ROC) curve analysis. Finally, the diagnostic performance of each risk factor was evaluated by the Z-test. RESULTS A total of 116 patients who met the inclusion criteria were included in the final analysis (58 cases in the noncontact ACL injury group and 58 cases in the control group). Patients with noncontact ACL injury had a higher femoral LFCR (0.64 ± 0.03) than patients with isolated meniscus tears. Among all the risk factors for ACL injury, the AUC for LFCR was the largest, at 0.81 (95% CI, 0.73-0.88), and when the critical value was 0.61, the sensitivity and specificity for the diagnosis of ACL injury were 0.79 and 0.67, respectively. When combined with LTH (> 2.35 mm), the diagnostic performance was improved. The AUC was 0.85 (95% CI, 0.78-0.92), the sensitivity was 0.83, and the specificity was 0.76. CONCLUSION This study shows that an increased LFCR is related to an increased risk of noncontact ACL injury as determined by MRI. LFCR and LTH are sensitive risk factors for noncontact ACL injury and may help clinicians identify individuals prone to ACL injury, allowing prevention and intervention measures to be applied.
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Affiliation(s)
- Miao He
- Department of Orthopaedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), No. 1 Jiankang Road, Chongqing, 400010, China.
| | - Jie Li
- Department of Orthopaedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), No. 1 Jiankang Road, Chongqing, 400010, China
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15
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Fu C, Fan X, Jiang S, Wang J, Li T, Kang K, Gao S. Increased lateral and medial femoral posterior radius ratios are risk factors for anterior cruciate ligament injury. BMC Musculoskelet Disord 2022; 23:114. [PMID: 35123471 PMCID: PMC8818135 DOI: 10.1186/s12891-022-05052-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/21/2022] [Indexed: 12/02/2022] Open
Abstract
Background Many studies have shown that distal femoral sagittal morphological characteristics have a clear relationship with knee joint kinematics. The aim of this study was to determine the relationship between distal femoral sagittal morphological characteristics and noncontact anterior cruciate ligament (ACL) injury. Methods A retrospective case-control study of 148 patients was conducted. Two age- and sex-matched cohorts (each n = 74) were analysed: a noncontact ACL injury group and a control group. Several characteristics were compared between the two groups, including the lateral femoral posterior radius (LFPR), medial femoral posterior radius (MFPR), lateral height of the distal femur (LH), medial height of the distal femur (MH), lateral femoral anteroposterior diameter (LFAP), medial femoral anteroposterior diameter (MFAP), lateral femoral posterior radius ratio (LFPRR), and medial femoral posterior radius ratio (MFPRR). Receiver operating characteristic (ROC) analysis was used to evaluate the significance of the LFPRR and MFPRR in predicting ACL injury. Results Compared with patients in the control group, patients in the ACL injury group had an increased LFPR, MFPR, MFAP, LFPRR, and MFPRR. ROC analysis revealed that an increased LFPRR above 31.7% was associated with noncontact ACL injury, with a sensitivity of 78.4% and a specificity of 58.1%; additionally. an increased MFPRR above 33.4% was associated with noncontact ACL injury, with a sensitivity of 58.1% and a specificity of 70.3%. Conclusion This study showed that increased LFPRR and increased MFPRR are risk factors for developing noncontact ACL injury. These data could thus help identify individuals susceptible to ACL injuries.
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16
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Winkler PW, Wagala NN, Hughes JD, Lesniak BP, Musahl V. A high tibial slope, allograft use, and poor patient-reported outcome scores are associated with multiple ACL graft failures. Knee Surg Sports Traumatol Arthrosc 2022; 30:139-148. [PMID: 33517476 PMCID: PMC8800919 DOI: 10.1007/s00167-021-06460-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/18/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare clinical outcomes, radiographic characteristics, and surgical factors between patients with single and multiple anterior cruciate ligament (ACL) graft failures. It was hypothesized that patients experiencing multiple ACL graft failures exhibit lower patient-reported outcome scores (PROs) and a higher (steeper) posterior tibial slope (PTS) than patients with single ACL graft failure. METHODS Patients undergoing revision ACL reconstruction with a minimum follow-up of 12 months were included in this retrospective cohort study. Based on the number of ACL graft failures, patients were assigned either to the group "single ACL graft failure "or" multiple ACL graft failures ". The PTS was measured on strict lateral radiographs. Validated PROs including the International Knee Documentation Committee (IKDC) subjective knee form, Knee Injury and Osteoarthritis Outcome Score, Lysholm Score, Tegner Activity Scale, ACL-Return to Sport after Injury Scale, and Visual Analogue Scale for pain were collected. RESULTS Overall, 102 patients were included with 58 patients assigned to the single ACL graft failure group and 44 patients to the multiple ACL graft failures group. Quadriceps tendon autograft was used significantly more often (55% vs. 11%, p < 0.001) and allografts were used significantly less often (31% vs. 66%, p < 0.001) as the graft for first revision ACL reconstruction in patients with single versus multiple ACL graft failures. Patients with multiple ACL graft failures were associated with statistically significantly worse PROs (IKDC: 61.7 ± 19.3 vs. 77.4 ± 16.8, p < 0.05; Tegner Activity Scale: 4 (range, 0-7) vs. 6 (range 2-10), p < 0.05), higher PTS (12 ± 3° vs. 9 ± 3°, p < 0.001), and higher rates of subsequent surgery (73% vs. 14%, p < 0.001) and complications (45% vs. 17%, p < 0.05) than patients with single ACL graft failure. CONCLUSION Compared to single ACL graft failure in this study multiple ACL graft failures were associated with worse PROs, higher PTS, and allograft use. During the first revision ACL reconstruction, it is recommended to avoid the use of allografts and to consider slope-reducing osteotomies to avoid multiple ACL graft failures and improve PROs. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Philipp W. Winkler
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA 15203 USA ,Department for Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Nyaluma N. Wagala
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA 15203 USA
| | - Jonathan D. Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA 15203 USA
| | - Bryson P. Lesniak
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA 15203 USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA, 15203, USA.
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17
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Musahl V, Nazzal EM, Lucidi GA, Serrano R, Hughes JD, Margheritini F, Zaffagnini S, Fu FH, Karlsson J. Current trends in the anterior cruciate ligament part 1: biology and biomechanics. Knee Surg Sports Traumatol Arthrosc 2022; 30:20-33. [PMID: 34927221 DOI: 10.1007/s00167-021-06826-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/23/2021] [Indexed: 11/27/2022]
Abstract
A trend within the orthopedic community is rejection of the belief that "one size fits all." Freddie Fu, among others, strived to individualize the treatment of anterior cruciate ligament (ACL) injuries based on the patient's anatomy. Further, during the last two decades, greater emphasis has been placed on improving the outcomes of ACL reconstruction (ACL-R). Accordingly, anatomic tunnel placement is paramount in preventing graft impingement and restoring knee kinematics. Additionally, identification and management of concomitant knee injuries help to re-establish knee kinematics and prevent lower outcomes and registry studies continue to determine which graft yields the best outcomes. The utilization of registry studies has provided several large-scale epidemiologic studies that have bolstered outcomes data, such as avoiding allografts in pediatric populations and incorporating extra-articular stabilizing procedures in younger athletes to prevent re-rupture. In describing the anatomic and biomechanical understanding of the ACL and the resulting improvements in terms of surgical reconstruction, the purpose of this article is to illustrate how basic science advancements have directly led to improvements in clinical outcomes for ACL-injured patients.Level of evidenceV.
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Affiliation(s)
- Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | - Ehab M Nazzal
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA.
| | - Gian Andrea Lucidi
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA.,IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Rafael Serrano
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | | | - Stefano Zaffagnini
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Freddie H Fu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | - Jon Karlsson
- The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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18
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Dietvorst M, Verhagen S, van der Steen MCM, Faunø P, Janssen RPA. Lateral tibiofemoral morphometry does not identify risk of re-ruptures after ACL reconstruction in children and adolescents. J Exp Orthop 2021; 8:88. [PMID: 34623550 PMCID: PMC8501174 DOI: 10.1186/s40634-021-00403-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/06/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Martijn Dietvorst
- Department of Orthopaedic Surgery & Trauma, Máxima MC, Eindhoven, the Netherlands.
| | - Stéphanie Verhagen
- Department of Orthopaedic Surgery & Trauma, Máxima MC, Eindhoven, the Netherlands
| | - M C Marieke van der Steen
- Department of Orthopaedic Surgery & Trauma, Máxima MC, Eindhoven, the Netherlands.,Department of Orthopaedic Surgery & Trauma, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Peter Faunø
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Rob P A Janssen
- Department of Orthopaedic Surgery & Trauma, Máxima MC, Eindhoven, the Netherlands.,Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands.,Chair Value-Based Health Care, Department of Paramedical Sciences, Fontys University of Applied Sciences, Eindhoven, the Netherlands
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19
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Lucidi GA, Dunn R, Wagala NN, Musahl V. Editorial Commentary: The Importance of Bony Morphology in the Anterior Cruciate Ligament-Injured Patient. Arthroscopy 2021; 37:3166-3169. [PMID: 34602156 DOI: 10.1016/j.arthro.2021.05.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 02/02/2023]
Abstract
The outcome of anterior cruciate ligament (ACL) surgery depends on many factors. Successful ACL surgery includes evaluating patients' characteristics and addressing all the underlying knee pathologies, including the meniscus tears and ramp lesions. In recent years, there has been a growing interest in ramp lesions as well as the role that bony morphology plays in predisposing patients to ACL injury and failed ACL surgery. Not only pathologic but also physiologic variations in bony morphology like tibial slope and lateral femoral condyle ratio have been correlated with clinical outcomes, failure rates, rotatory instability, and even lesions to the contralateral knee. Evaluating each patient's specific anatomy is recommended when customizing ACL surgery. With further research and increased awareness of relevant bony parameters, we will be able to improve our ability to prevent injury, increase the diagnostic accuracy of associated lesions, and tailor surgery to improve the outcomes and reduce failure rates.
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20
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Kim SH, Park YB, Won YS. An Increased Lateral Femoral Condyle Ratio Is an Important Risk Factor for a Medial Meniscus Ramp Lesion Including Red-Red Zone Tear. Arthroscopy 2021; 37:3159-3165. [PMID: 33892074 DOI: 10.1016/j.arthro.2021.03.078] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE This study aimed to determine radiological findings associated with ramp lesions in knees with anterior cruciate ligament (ACL) injury. METHODS This study included the primary ACL reconstructions from June 2011 to March 2019. The exclusion criteria were combined fractures and multiligament injuries. Patients were categorized based on arthroscopy-confirmed presence of ramp lesions, which was defined as a longitudinal tear around the meniscocapsular junction or red-red zone tear of medial meniscus posterior horn. Binary logistic regression analysis was performed to find the risk factors such as age, sex, body mass index, medial tibial slope, mechanical axis angle, presence of Segond fracture, and lateral femoral condyle (LFC) ratio. Additionally, receiver operating characteristic (ROC) curves and area under the ROC curve (AUC) were evaluated. RESULTS Ramp lesions were identified in 89 (27.7%) patients among the total 321 included primary ACL reconstructions. The risk of ramp lesion was associated with increased LFC ratio (odds ratio [OR]: 62.929; 95% confidence interval [CI]: 8.473-467.351; P < .001), varus alignment >3° (OR: 5.858; 95% CI: 3.272-10.486; P < .001), and steeper medial tibial slope (OR: 1.183; 95% CI: 1.05-1.333; P = .006). The cutoff values of the LFC ratio and medial tibial slope for ramp lesions were >71% (AUC: 0.696; sensitivity: 43.82%; specificity: 91.38%; P < .001) and >12.1° (AUC: 0.643; sensitivity: 85.39%; specificity: 38.79%; P < .001), respectively. CONCLUSION Deep posterior LFC, varus alignment, and steep medial tibial slope were associated factors for ramp lesions in knees with ACL injury. In patients with ACL injury who show the above-mentioned radiographic findings, careful assessment and suspicion for ramp lesions should be considered. STUDY DESIGN Level III, retrospective cross-sectional study.
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Affiliation(s)
- Seong Hwan Kim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Yong-Beom Park
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, South Korea.
| | - Yoo-Sun Won
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, South Korea
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Winkler PW, Wagala NN, Hughes JD, Irrgang JJ, Fu FH, Musahl V. Association Between Meniscal Allograft Tears and Early Surgical Meniscal Allograft Failure. Am J Sports Med 2021; 49:3302-3311. [PMID: 34399055 DOI: 10.1177/03635465211032970] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Meniscal allograft transplantation (MAT) has become a viable treatment option for patients with symptomatic meniscal deficiency. Some patients experience early surgical meniscal allograft failure attributed to causes that have not yet been sufficiently clarified. PURPOSE To evaluate the prevalence, types, and distribution of arthroscopically confirmed meniscal allograft tears and the associated effect on surgical meniscal allograft survival. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Patients undergoing MAT with a minimum 2-year follow-up were retrospectively reviewed. Descriptive and surgical data were collected. Type and location of arthroscopically confirmed meniscal allograft tears were recorded and compared between medial and lateral allografts and suture-only and bone block fixation. A survival analysis was conducted to evaluate the effect of meniscal allograft tears on surgical meniscal allograft survival. RESULTS This study included 142 patients (54% male; mean ± SD age, 29.6 ± 10.4 years) with a mean follow-up of 10.3 ± 7.5 years. The prevalence of meniscal allograft tears was 32%, observed at a median of 1.2 years (interquartile range, 2.8 years) after MAT. The posterior horns were most frequently affected, followed by the posterior roots, midbodies, anterior horns, and anterior roots. The most frequently observed tear types were root tears (43%), followed by longitudinal, horizontal, radial, complex, bucket-handle, and meniscocapsular separation tears. A statistically significant association was found between meniscal allograft tear types and fixation techniques (P = .027), with root tears predominant after suture-only as compared with bone block fixation (57% vs 22%). Patients with meniscal allograft root tears were a mean of 5.4 years (95% CI, 1.6-9.2 years; P = .007) younger than were patients without root tears. The 1-year surgical meniscal allograft survival rate was significantly lower for torn versus intact meniscal allografts (75% vs 99%; P < .001). CONCLUSION Meniscal allograft root tears were predominant, associated with younger patient age, and more often observed when using the suture-only fixation technique versus the bone block fixation technique. Torn meniscal allografts were associated with early surgical graft failure when compared with intact meniscal allografts, resulting in a significantly lower 1-year survival rate.
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Affiliation(s)
- Philipp W Winkler
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department for Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Nyaluma N Wagala
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James J Irrgang
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Diermeier T, Rothrauff BB, Engebretsen L, Lynch AD, Svantesson E, Hamrin Senorski E, Rauer T, Meredith SJ, Ayeni OR, Paterno MV, Xerogeanes JW, Fu FH, Karlsson J, Musahl V. Treatment after anterior cruciate ligament injury: Panther Symposium ACL Treatment Consensus Group. J ISAKOS 2021; 6:129-137. [PMID: 34006576 DOI: 10.1136/jisakos-2020-000493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2020] [Indexed: 01/25/2023]
Abstract
Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance towards consensus opinions regarding the best available evidence on operative versus non-operative treatment for ACL injury.The purpose of this study was to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs for the three working groups. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative veresus non-operative treatment of ACL injury reached consensus during the symposium. Nine statements achieved unanimous support; two reached strong consensus; one did not achieve consensus; and one was removed due to redundancy in the information provided.In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical anterior cruciate ligament reconstruction (ACLR) is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability or when episodes of giving way occur, anatomical ACLR is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injury.Level of evidence: V.
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Affiliation(s)
- Theresa Diermeier
- Department of Sportorthopedic, Technical University of Munich, Munchen, Germany
| | - Benjamin B Rothrauff
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lars Engebretsen
- Department of Orthopedics, Institute of Clinical Sciences, University of Gothenburg, Mölndal, Sweden
| | | | - Eleonor Svantesson
- Department of Orthopedics, Institute of Clinical Sciences, University of Gothenburg, Mölndal, Sweden
| | | | | | - Sean J Meredith
- Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Olufemi R Ayeni
- Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Mark V Paterno
- Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - John W Xerogeanes
- Department of Orthopaedics, Emory University Orthopaedic and Spine Hospital, Atlanta, Georgia, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jón Karlsson
- Department of Orthopaedics, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Lucidi GA, Grassi A, Di Paolo S, Agostinone P, Neri MP, Macchiarola L, Dal Fabbro G, Zaffagnini S. The Lateral Femoral Notch Sign Is Correlated With Increased Rotatory Laxity After Anterior Cruciate Ligament Injury: Pivot Shift Quantification With A Surgical Navigation System. Am J Sports Med 2021; 49:649-655. [PMID: 33449808 DOI: 10.1177/0363546520982002] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The lateral femoral notch sign (LNS) is a bony impression on the lateral femoral condyle correlated with anterior cruciate ligament (ACL) injury. Its presence is associated with lateral meniscal injury and higher cartilage degradation on the lateral femoral condyle. PURPOSE/HYPOTHESIS The purpose was to investigate the effect of the presence and magnitude of LNS on rotatory instability. The hypothesis was that a positive LNS is correlated with a high-grade pivot shift (PS). STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A total of 90 consecutive patients with complete ACL tears between 2013 and 2017 underwent intraoperative kinematic evaluation with the surgical navigation system and were included in the present study. The same surgeon performed a standardized PS under anesthesia. The PS was quantified through the acceleration of the lateral compartment during tibial reduction (PS ACC) and the internal-external rotation (PS IE). Presence and depth of LNS were evaluated on sagittal magnetic resonance images (1.5-T). RESULTS In 47 patients, the LNS was absent; in 33, the LNS depth was between 1 mm and 2 mm; and in 10 patients, it was deeper than 2 mm. Patients with a notch deeper than 2 mm showed increased PS ACC and PS IE compared with the group without the LNS. However, no significant differences were present between the group with a notch between 1 and 2 mm and the patients without LNS. Receiver operating characteristic curve analysis showed that 2 mm was the most predictive cutoff value to identify the "high-grade rotatory instability" group, with an accuracy of 77.8% and 74.4% and a specificity of 95.5% and 93.9% referred to the PS ACC and PS IE, respectively. CONCLUSION The presence of a lateral LNS deeper than 2 mm could be used for the preoperative identification of patients with a high risk of increased rotatory instability.
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Affiliation(s)
- Gian Andrea Lucidi
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alberto Grassi
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Di Paolo
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Piero Agostinone
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Maria Pia Neri
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Luca Macchiarola
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giacomo Dal Fabbro
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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24
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Pearle AD, Nawabi DH, Marom N, Wickiewicz TL, Imhauser CW. Editorial Commentary: The Pivot Shift and Lachman Examinations: Teammates With Distinct Roles. Arthroscopy 2021; 37:682-685. [PMID: 33546804 DOI: 10.1016/j.arthro.2020.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/01/2020] [Indexed: 02/02/2023]
Abstract
The pivot shift and Lachman examinations are "teammates" with complementary but distinct roles in the successful diagnosis and treatment of anterior cruciate ligament rupture and injury to the surrounding soft-tissue envelope of the knee. The Lachman test measures anterior tibial translation in response to an applied anterior tibial load. This test assesses the integrity of the native or reconstructed anterior cruciate ligament and the secondary medial restraints including the medial meniscus and medial collateral ligament. In contrast, the pivot shift exam creates coupled tibiofemoral motions in response to a complex combination of multiplanar loads. This test assesses the stabilizing role of the native or reconstructed anterior cruciate ligament and the secondary lateral restraints including the lateral meniscus and anterolateral complex. The pivot shift grade depends not only on the soft the tissue stabilizers of the knee but also on the shape of the proximal tibia and the distal femur including lateral tibial slope and femoral condylar offset. Both examinations have unique strengths and weaknesses, but when combined as diagnostic tools, they achieve far more collectively than what each can achieve alone.
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25
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Knee laxity, lateral meniscus tear and distal femur morphology influence pivot shift test grade in ACL injury patients. Knee Surg Sports Traumatol Arthrosc 2021; 29:633-640. [PMID: 32303800 DOI: 10.1007/s00167-020-05994-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 04/10/2020] [Indexed: 01/12/2023]
Abstract
PURPOSE Although several factors have been considered to be associated with pivot shift test grade in ACL injured patients, a conclusion regarding which factors contribute to the pivot shift test grade has not been reached. The purpose of this study was to identify factors associated with preoperative pivot shift test grade. METHODS Three hundred and sixty-six consecutive patients who underwent ACL reconstruction in our hospital were enrolled in the study. Patients were divided into two groups on the basis of preoperative pivot shift test grade (Mild: grade 0-3, Severe: grade 4-6). First, 13 independent variables (age, gender, period from injury to surgery, hyperextension, KT measurement, contralateral side pivot shift test grade, medial and lateral tibial slope, lateral condyle length, lateral condyle height, distal femoral condyle offset, medial and lateral meniscus tear) were analyzed by one-way ANOVA and Chi-squared test. Binary Logistic regression was then performed based on the results of univariate analyses (independent variables of p < 0.2 were included). RESULTS Hyperextension, lateral meniscus tear, contralateral side pivot shift test grade, distal femoral condyle offset and KT measurement were identified as risk factors for preoperative pivot shift grade via logistic regression analysis. CONCLUSION The current study revealed that hyperextension, lateral meniscus tear, contralateral side pivot shift test grade, distal femoral condyle offset and anterior instability were associated with preoperative pivot shift grade. Patients with above factors that cannot be modified during surgery may need special consideration when ACL reconstruction is performed, as greater preoperative pivot shift has been proven to be a risk factor for residual pivot shift after ACL reconstruction. LEVEL OF EVIDENCE III.
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26
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Sheean AJ, Lian J, Tisherman R, Meredith SJ, de Sa D, Lynch A, Lesniak BP, Musahl V. Augmentation of Anatomic Anterior Cruciate Ligament Reconstruction With Lateral Extra-articular Tenodesis Does Not Significantly Affect Rotatory Knee Laxity: A Time Zero, In Vivo Kinematic Analysis. Am J Sports Med 2020; 48:3495-3502. [PMID: 33176107 DOI: 10.1177/0363546520966624] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The pivot-shift test is used to assess for rotatory knee laxity in the anterior cruciate ligament (ACL)-deficient knee and ACL-reconstructed knee; however, the pivot shift uses a subjective grading system that is limited by variability between examiners. Consequently, quantified pivot shift (QPS) test software (PIVOT iPad application) has been developed and validated to measure the magnitude of rotatory knee laxity during the positive pivot-shift test. PURPOSE To employ intraoperative QPS (iQPS) to assess for differences in residual rotatory knee laxity after ACL reconstruction (ACLR) versus ACLR augmented with lateral extra-articular tenodesis (ACLR + LET), and to employ iQPS to determine if ACLR and/or ACLR + LET result in overconstrained knee kinematics when compared with the contralateral knee. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS iQPS was performed in 20 patients by a single surgeon on both the operative and contralateral knees before ACLR. ACLR was augmented with a LET if the lateral compartment tibial translation measured during QPS was greater than or equal to double the amount of lateral tibial compartment translation measured for the contralateral knee. After each reconstruction (ACLR or ACLR + LET), iQPS measurements were performed. iQPS data were compared with the preoperative QPS measurements of the operative and contralateral knees. Postoperative iQPS data were compared with both the preoperative QPS measurements of the operative and contralateral knees with paired samples t tests. Categorical variables were compared using the Fisher exact test. RESULTS The mean age in the cohort was 17.3 years (range, 15-24 years). There were no significant differences between the groups in terms of the proportion of male patients (ACLR: 5 male, 5 female vs ACLR + LET: 4 male, 6 female) or age (ACLR: 17.7 ± 3.3 years; 95% CI, 15.4-24.0 vs ACLR + LET: 16.8 ± 2.8 years, 95% CI, 14.8-22.0; P = .999). There were no significant differences between the groups with respect to preoperative QPS performed during examination under anesthesia (ACLR: 4.7 ± 2.0 mm; 95% CI, 3.3-6.1 vs ACLR + LET: 3.6 ± 1.8 mm; 95% CI, 2.3-4.9; P = .2). Both ACLR and ACLR + LET resulted in significant decreases in rotatory knee laxity when compared with preoperative QPS measurements (ACLR: -3.4 ± 1.7 mm; 95% CI, -4.6 to -2.2; P < .001: ACLR + LET: -2.6 ± 1.9 mm; 95% CI, -3.9 to -1.3; P < .002). Moreover, when compared with isolated ACLR, ACLR + LET did not result in a significantly smaller magnitude of change in iQPS between the pre- and postoperative states (P = .3). CONCLUSION Both ACLR and ACLR + LET resulted in significant decreases in rotatory knee laxity. The augmentation of ACLR with LET did not change the constraint of the knee with respect to lateral compartment translation as measured during iQPS.
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Affiliation(s)
- Andrew J Sheean
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Jayson Lian
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert Tisherman
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sean J Meredith
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Darren de Sa
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Lynch
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bryson P Lesniak
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Ferretti A, Monaco E, Gaj E, Andreozzi V, Annibaldi A, Carrozzo A, Vieira TD, Sonnery-Cottet B, Saithna A. Risk Factors for Grade 3 Pivot Shift in Knees With Acute Anterior Cruciate Ligament Injuries: A Comprehensive Evaluation of the Importance of Osseous and Soft Tissue Parameters From the SANTI Study Group. Am J Sports Med 2020; 48:2408-2417. [PMID: 32631068 DOI: 10.1177/0363546520935866] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preoperative grade 3 pivot shift has been reported to be associated with higher rates of anterior cruciate ligament (ACL) failure, persistent instability, and inferior patient-reported outcomes. The etiology of a high-grade pivot shift is multifactorial, and numerous factors have been suggested to be responsible. More attention has recently been focused on injury to the anterolateral structures (ALS) as a risk factor for a grade 3 pivot shift. PURPOSE To determine risk factors for grade 3 pivot shift, including soft tissue and osseous parameters. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A prospective evaluation was undertaken of 200 consecutive patients undergoing acute ACL reconstruction (within 10 days of injury). An open exploration of the lateral side of the injured knee was performed at the time of the index procedure. Details regarding patient and injury characteristics were recorded, as were details of soft tissue injuries, including meniscal tears, ALS lesions, medial collateral ligament tears, and chondral injuries. Osseous parameters (tibial slope and condylar ratios) were determined per established magnetic resonance imaging protocols. A multivariate logistic regression with penalized maximum likelihood was used to identify risk factors associated with International Knee Documentation Committee (IKDC) grade 3 pivot shift. RESULTS The mean ± SD age of the population was 28.3 ± 9.8 years; 67.5% of patients were male. Among patients, 35 (17.5%) had a high-grade pivot shift (IKDC grade 3), and 165 (82.5%) had a low-grade pivot shift (IKDC grades 1 and 2). Univariate and multivariate logistic regression analysis demonstrated that injury to the ALS was the only significant risk factor for grade 3 pivot shift (odds ratio, 13.49; 95% CI, 1.80-1725.53). CONCLUSION This comprehensive evaluation of soft tissue and osseous factors has identified that injury to the ALS is the most important risk factor for grade 3 pivot shift in acute ACL-injured knees.
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Affiliation(s)
- Andrea Ferretti
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, Sant'Andrea Hospital, University of Rome La Sapienza, Rome, Italy
| | - Edoardo Monaco
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, Sant'Andrea Hospital, University of Rome La Sapienza, Rome, Italy
| | - Edoardo Gaj
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, Sant'Andrea Hospital, University of Rome La Sapienza, Rome, Italy
| | - Valerio Andreozzi
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, Sant'Andrea Hospital, University of Rome La Sapienza, Rome, Italy
| | - Alessandro Annibaldi
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, Sant'Andrea Hospital, University of Rome La Sapienza, Rome, Italy
| | - Alessandro Carrozzo
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, Sant'Andrea Hospital, University of Rome La Sapienza, Rome, Italy
| | - Thais Dutra Vieira
- Centre Orthopédique Santy; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Adnan Saithna
- Kansas City University of Medicine and Biosciences, Kansas City, Missouri, USA
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Diermeier TA, Rothrauff BB, Engebretsen L, Lynch A, Svantesson E, Hamrin Senorski EA, Meredith SJ, Rauer T, Ayeni OR, Paterno M, Xerogeanes JW, Fu FH, Karlsson J, Musahl V. Treatment after ACL injury: Panther Symposium ACL Treatment Consensus Group. Br J Sports Med 2020; 55:14-22. [DOI: 10.1136/bjsports-2020-102200] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2020] [Indexed: 01/13/2023]
Abstract
Treatment strategies for ACL injuries continue to evolve. Evidence supporting best practice guidelines to manage ACL injury is largely based on studies with low-level evidence. An international consensus group of experts was convened determine consensus regarding best available evidence on operative versus non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus non-operative treatment of ACL injury reached consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomical ACL reconstruction is indicated. The consensus statements derived from international leaders in the field may assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injury. Level of evidence: Level V
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29
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Diermeier T, Meredith SJ, Irrgang JJ, Zaffagnini S, Kuroda R, Hochino Y, Samuelsson K, Smith CN, Popchak A, Musahl V, Sheean A, Burnham JM, Lian J, Smith C, Popchak A, Herbst E, Pfeiffer T, Araujo P, Oostdyk A, Guenther D, Ohashi B, Irrgang JJ, Fu FH, Nagamune K, Kurosaka M, Kuroda R, Hochino Y, Grassi A, Muccioli GMM, Lopomo N, Signorelli C, Raggi F, Zaffagnini S, Horvath A, Svantesson E, Senorski EH, Sundemo D, Bjoernsson H, Ahlden M, Desai N, Samuelsson K, Karlsson J. Patient-Reported and Quantitative Outcomes of Anatomic Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Autografts. Orthop J Sports Med 2020; 8:2325967120926159. [PMID: 32685564 PMCID: PMC7343370 DOI: 10.1177/2325967120926159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/19/2020] [Indexed: 01/17/2023] Open
Abstract
Background: The pivot-shift test has become more consistent and reliable and is a meaningful outcome measurement after anterior cruciate ligament reconstruction (ACLR). Purpose/Hypothesis: The purpose of this investigation was to assess patient-reported outcomes (PROs) and the quantitative pivot shift (QPS) preoperatively, at time zero immediately after anatomic ACLR, and after 24 months as well as the relationship between PROs and the QPS. It was hypothesized that anatomic ACLR would restore rotatory stability measured by the pivot-shift test and that QPS measurements would be positively correlated with PROs. Study Design: Cohort study; Level of evidence, 2. Methods: The ACL-injured and contralateral uninjured knees from 89 of 107 (83.2%) enrolled patients at 4 international centers were evaluated using a standardized pivot-shift test. Tibial acceleration was assessed with an inertial sensor, and lateral compartment translation was measured using an image analysis system preoperatively, at time zero immediately postoperatively, and at follow-up after 2 years. PROs were assessed at 12 and 24 months postoperatively with the International Knee Documentation Committee (IKDC) subjective knee form, Cincinnati Knee Rating System (CKRS), Marx activity rating scale, and activity of daily living score (ADLS). Results: The mean patient age at surgery was 27 years (range, 15-45 years). A positive pivot shift preoperatively (side-to-side difference in tibial acceleration, 2.6 ± 4.0 m/s2; side-to-side difference in anterior tibial translation, 2.0 ± 2.0 mm) was reduced at time zero postoperatively (side-to-side difference in tibial acceleration, –0.5 ± 1.3 m/s2; side-to-side difference in anterior tibial translation, –0.1 ± 1.0 mm). All PROs improved from preoperatively to final follow-up at 24 months: from 56.5 to 85.5 points for the IKDC (P = .0001), from 28.8 to 32.4 points for the CKRS (P = .04), from 11.2 to 7.9 points for the Marx (P < .0001), and from 75.7 to 91.6 points for the ADLS (P < .0001). Neither preoperative nor time zero postoperative rotatory laxity assessed by the pivot-shift test correlated with PROs at 24-month follow-up. A graft retear was observed in 4 patients (4.5%) within 2 years of follow-up. Conclusion: Anatomic ACLR resulted in significantly improved and acceptable PROs at 2-year follow-up and a low failure rate. Anatomic ACLR restored QPS measurements of anterior tibial translation and tibial acceleration to those of the contralateral knee immediately after surgery while still under anesthesia, but there was no correlation between the QPS preoperatively or at time zero after ACLR and PROs at 2-year follow-up.
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Affiliation(s)
- Theresa Diermeier
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sean J Meredith
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James J Irrgang
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Stefano Zaffagnini
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ryosuke Kuroda
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yuichi Hochino
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kristian Samuelsson
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Clair Nicole Smith
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adam Popchak
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Andrew Sheean
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeremy M Burnham
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jayson Lian
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Clair Smith
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adam Popchak
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elmar Herbst
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Thomas Pfeiffer
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Paulo Araujo
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alicia Oostdyk
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel Guenther
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bruno Ohashi
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James J Irrgang
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Freddie H Fu
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kouki Nagamune
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Masahiro Kurosaka
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ryosuke Kuroda
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yuichi Hochino
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alberto Grassi
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Nicola Lopomo
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Cecilia Signorelli
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Federico Raggi
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Stefano Zaffagnini
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alexandra Horvath
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eleonor Svantesson
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eric Hamrin Senorski
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David Sundemo
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Haukur Bjoernsson
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mattias Ahlden
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Neel Desai
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kristian Samuelsson
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jon Karlsson
- Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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30
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Diermeier T, Rothrauff BB, Engebretsen L, Lynch AD, Ayeni OR, Paterno MV, Xerogeanes JW, Fu FH, Karlsson J, Musahl V, Brown CH, Chmielewski TL, Clatworthy M, Villa SD, Ernlund L, Fink C, Getgood A, Hewett TE, Ishibashi Y, Johnson DL, Macalena JA, Marx RG, Menetrey J, Meredith SJ, Onishi K, Rauer T, Rothrauff BB, Schmitt LC, Seil R, Senorski EH, Siebold R, Snyder-Mackler L, Spalding T, Svantesson E, Wilk KE. Treatment After Anterior Cruciate Ligament Injury: Panther Symposium ACL Treatment Consensus Group. Orthop J Sports Med 2020; 8:2325967120931097. [PMID: 32637434 PMCID: PMC7315684 DOI: 10.1177/2325967120931097] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/03/2020] [Indexed: 12/14/2022] Open
Abstract
Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best-practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative versus nonoperative treatment for ACL injury. The purpose of this study was to report the consensus statements on operative versus nonoperative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. There were 66 international experts on the management of ACL injuries, representing 18 countries, who were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the scientific organizing committee and session chairs for the 3 working groups. Panel participants reviewed preliminary statements before the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Ultimately, 80% agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus nonoperative treatment of ACL injury reached consensus during the symposium. Overall, 9 statements achieved unanimous support, 2 reached strong consensus, 1 did not achieve consensus, and 1 was removed because of redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended because of the high risk of secondary meniscal and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight-plane activities, nonoperative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and nonoperative treatment with patients after an ACL injury.
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Affiliation(s)
- Theresa Diermeier
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Benjamin B Rothrauff
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lars Engebretsen
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew D Lynch
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Olufemi R Ayeni
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mark V Paterno
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John W Xerogeanes
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Freddie H Fu
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jon Karlsson
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Charles H Brown
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Terese L Chmielewski
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mark Clatworthy
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Stefano Della Villa
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lucio Ernlund
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christian Fink
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alan Getgood
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Timothy E Hewett
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yasuyuki Ishibashi
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Darren L Johnson
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeffrey A Macalena
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert G Marx
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jacques Menetrey
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sean J Meredith
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kentaro Onishi
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Thomas Rauer
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Benjamin B Rothrauff
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Laura C Schmitt
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Romain Seil
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eric H Senorski
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rainer Siebold
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lynn Snyder-Mackler
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tim Spalding
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eleonore Svantesson
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kevin E Wilk
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Li R, Yuan X, Fang Z, Liu Y, Chen X, Zhang J. A decreased ratio of height of lateral femoral condyle to anteroposterior diameter is a risk factor for anterior cruciate ligament rupture. BMC Musculoskelet Disord 2020; 21:402. [PMID: 32576249 PMCID: PMC7313127 DOI: 10.1186/s12891-020-03440-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/18/2020] [Indexed: 01/13/2023] Open
Abstract
Background Studies have shown that the spherical shape of the lateral femoral condyle has a clear relationship with the relative axial movement of tibiofemoral joint and the anterior cruciate ligament (ACL) rupture. The purpose of this study was to describe the distal curvature of the lateral femoral condyle by ratio of height of lateral femoral condyle to anteroposterior diameter (HAPR), and evaluate its correlation with ACL rupture. Methods A retrospective case-control study of 64 patients was conducted. Two age-and sex-matched cohorts (each n = 32) were analyzed: primary ACL ruptures, and a control group consisting of isolated meniscal tears. On the radiograph, the distance from the intersection of the axis of the distal femur and the anteriorly diameter of the lateral femoral condyle to the lower point of the lateral femoral condyle divided by the anteriorly diameter of the lateral femoral condyle is HAPR. The HAPR was measured by digital radiograph imaging systems (DR) to quantify femoral sphericity. Cutoff values were defined; and diagnostic performance of the risk factors was assessed. Meanwhile, we measured the posterior tibial slope (PTS) on radiograph and compared the two methods to evaluate the significance of HAPR in predicting ACL rupture. Results A total of sixty-four patients who met the inclusion criteria were included in the final analysis (32 with primary ACL rupture, 32 controls). The HAPR was smaller in the knees with primary ACL rupture (0.31 ± 0.02) than that of the control group (0.33 ± 0.02) (p < 0.01). The PTS was bigger in the knees with primary ACL rupture (8.18 ± 2.77) than that of the control group (6.61 ± 2.85) (p = 0.036). The AUC of HAPR was bigger (0.825; 95% CI, 0.72–0.93) than that of PTS (0.675; 95%CI, 0.85–0.81). The calculated cutoff of HAPR of 0.32 (Youden index, 0.56) was associated with an increased risk for ACL rupture, with sensitivity of 75% and specificity of 81% to predict an ACL rupture. Conclusions This study showed that a decreased HAPR is associated with an ACL rupture, and the decrease of HAPR was more significant in predicting ACL ruptures than the PTS. This helps clinicians identify susceptible individuals who may benefit from targeted ACL rupture prevention counseling and intervention.
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Affiliation(s)
- Ruibo Li
- Department of Orthopaedics, People's Hospital of Deyang City, No. 173, section 3, North Taishan Road, Deyang, 618000, Sichuan Province, China.
| | - Xingyue Yuan
- Medical College, Qingdao University, Qingdao, 266000, Shandong Province, China
| | - Zhi Fang
- Department of Orthopaedics, People's Hospital of Deyang City, No. 173, section 3, North Taishan Road, Deyang, 618000, Sichuan Province, China
| | - Yuehong Liu
- Department of Orthopaedics, People's Hospital of Deyang City, No. 173, section 3, North Taishan Road, Deyang, 618000, Sichuan Province, China
| | - Xi Chen
- Department of Orthopaedics, People's Hospital of Deyang City, No. 173, section 3, North Taishan Road, Deyang, 618000, Sichuan Province, China
| | - Jianjun Zhang
- Department of Orthopaedics, People's Hospital of Deyang City, No. 173, section 3, North Taishan Road, Deyang, 618000, Sichuan Province, China
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32
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Nishida K, Matsushita T, Hoshino Y, Araki D, Matsumoto T, Niikura T, Kuroda R. The Influences of Chronicity and Meniscal Injuries on Pivot Shift in Anterior Cruciate Ligament-Deficient Knees: Quantitative Evaluation Using an Electromagnetic Measurement System. Arthroscopy 2020; 36:1398-1406. [PMID: 32001277 DOI: 10.1016/j.arthro.2020.01.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 12/31/2019] [Accepted: 01/03/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the influences of time from injury to surgery and meniscal injuries on knee rotational laxity in anterior cruciate ligament (ACL)-deficient knees using the electromagnetic system retrospectively. METHODS Ninety-four unilateral ACL-injured patients (44 male and 50 female, mean age: 27.3 ± 11.8 years) were included. The pivot-shift test was performed before ACL reconstruction, as was a quantitative evaluation using the electromagnetic system to determine tibial acceleration. Patients were divided into 4 groups according to the chronicity: group 1, within 3 months (22 patients); group 2, between 3 and 6 months (29 patients); group 3, between 6 and 12 months (23 patients); and group 4, more than 12 months (20 patients). The presence of meniscal injuries was examined arthroscopically. RESULTS The tibial acceleration was significantly greater in group 4. There was a positive correlation between tibial acceleration and the time from injury to surgery (r = 0.47, P = .02). In groups 1, 2 and 3, the tibial acceleration in patients with a lateral meniscal injury was significantly greater than in patients with a medial meniscal injury and without meniscal injury. When patients with lateral meniscal injury were excluded (leaving those with medial meniscus injury or without meniscal injury), group 4 had significantly greater accelerations than other groups. CONCLUSIONS In ACL-deficient knees, rotational laxity increased with time and the increased rotational laxity was evident more than 1 year after injury whereas it increased with concomitant lateral meniscal injuries within 1 year after injury. LEVEL OF EVIDENCE Ⅳ, diagnostic study of nonconsecutive patients.
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Affiliation(s)
- Kyohei Nishida
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Daisuke Araki
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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33
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Bayer S, Meredith SJ, Wilson KW, de Sa D, Pauyo T, Byrne K, McDonough CM, Musahl V. Knee Morphological Risk Factors for Anterior Cruciate Ligament Injury: A Systematic Review. J Bone Joint Surg Am 2020; 102:703-718. [PMID: 31977822 DOI: 10.2106/jbjs.19.00535] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction incidence has increased substantially in the past 25 years. Recently, there has been a focus on knee morphology as a contributor to ACL injury risk. The purpose of this study was to systematically review the literature to assess the influence of knee morphology on ACL injury. METHODS In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, PubMed, Embase, and MEDLINE were searched in September 2017 for studies reporting on knee morphology and ACL injury. The search was updated in June 2018. The following inclusion criteria were used: English language; full text available; Level-I, II, or III evidence; human studies; and skeletally mature patients. RESULTS After systematically screening 6,208 studies, 65 studies met the inclusion/exclusion criteria. Three additional studies were identified in the search update, for a total of 68 studies comprising 5,834 ACL-injured knees. Intercondylar notch stenosis, most commonly defined by an "A-shaped" notch, decreased notch width, or decreased notch width index, was the most commonly reported femoral morphological risk factor for ACL injury. Increased femoral condylar offset ratio (>63%) and decreased condylar radius of curvature also were associated with an increased risk of ACL injury. Increased medial and lateral tibial slopes were the most commonly reported tibial risk factors. A smaller tibial eminence, reduced ACL size, and poor tibiofemoral congruity were also associated with increased injury risk. CONCLUSIONS Intercondylar notch stenosis, variations in sagittal condylar shape, increased tibial slope, reduced tibial eminence size, poor tibiofemoral congruity, and reduced ACL size are substantial risk factors for ACL injury. In future research, it would be valuable to identify a slope beyond which slope correction should be performed concomitantly with ACL reconstruction, and to determine whether an optimal relationship of notch size to graft size exists. To achieve optimal outcomes, the osseous morphological risk factors should be considered in individualized anatomic ACL reconstructions. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Steve Bayer
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sean J Meredith
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kevin W Wilson
- Department of Orthopaedic Surgery, Mount Nittany Health, State College, Pennsylvania
| | - Darren de Sa
- Department of Orthopaedic Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Thierry Pauyo
- Department of Orthopaedic Surgery, Shriners & Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Kevin Byrne
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christine M McDonough
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania.,UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Volker Musahl
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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34
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Lian J, Diermeier T, Meghpara M, Popchak A, Smith CN, Kuroda R, Zaffagnini S, Samuelsson K, Karlsson J, Irrgang JJ, Musahl V. Rotatory Knee Laxity Exists on a Continuum in Anterior Cruciate Ligament Injury. J Bone Joint Surg Am 2020; 102:213-220. [PMID: 31876642 DOI: 10.2106/jbjs.19.00502] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this investigation was to compare the magnitude of rotatory knee laxity in patients with a partial anterior cruciate ligament (ACL) tear, those with a complete ACL tear, and those who had undergone a failed ACL reconstruction. It was hypothesized that rotatory knee laxity would increase with increasing injury grade, with knees with partial ACL tears demonstrating the lowest rotatory laxity and knees that had undergone failed ACL reconstruction demonstrating the highest rotatory laxity. METHODS A prospective multicenter study cohort of 354 patients who had undergone ACL reconstruction between 2012 and 2018 was examined. All patients had both injured and contralateral healthy knees evaluated using standardized, preoperative quantitative pivot shift testing, determined by a validated, image-based tablet software application and a surface-mounted accelerometer. Quantitative pivot shift was compared with the contralateral healthy knee in 20 patients with partial ACL tears, 257 patients with complete ACL tears, and 27 patients who had undergone a failed ACL reconstruction. Comparisons were made using 1-way analysis of variance (ANOVA) with post hoc 2-sample t tests with Bonferroni correction. Significance was set at p < 0.05. RESULTS There were stepwise increases in side-to-side differences in quantitative pivot shift in terms of lateral knee compartment translation for patients with partial ACL tears (mean [and standard deviation], 1.4 ± 1.5 mm), those with complete ACL tears (2.5 ± 2.1 mm), and those who had undergone failed ACL reconstruction (3.3 ± 1.9 mm) (p = 0.01) and increases in terms of lateral compartment acceleration for patients with partial ACL tears (0.7 ± 1.4 m/s), those with complete ACL tears (2.3 ± 3.1 m/s), and those who had undergone failed ACL reconstruction (2.4 ± 5.5 m/s) (p = 0.01). A significant difference in lateral knee compartment translation was found when comparing patients with partial ACL tears and those with complete ACL tears (1.2 ± 2.1 mm [95% confidence interval (CI), 0.2 to 2.1 mm]; p = 0.02) and patients with partial ACL tears and those who had undergone failed ACL reconstruction (1.9 ± 1.7 mm [95% CI, 0.8 to 2.9 mm]; p = 0.001), but not when comparing patients with complete ACL tears and those who had undergone failed ACL reconstruction (0.8 ± 2.1 [95% CI, -0.1 to 1.6 mm]; p = 0.09). Increased lateral compartment acceleration was found when comparing patients with partial ACL tears and those with complete ACL tears (1.5 ± 3.0 m/s [95% CI, 0.8 to 2.3 m/s]; p = 0.0002), but not when comparing patients with complete ACL tears and those who had undergone failed ACL reconstruction (0.1 ± 3.4 m/s [95% CI, -2.2 to 2.4 m/s]; p = 0.93) or patients with partial ACL tears and those who had undergone failed ACL reconstruction (1.7 ± 4.2 m/s [95% CI, -0.7 to 4.0 m/s]; p = 0.16). An increasing lateral compartment translation of the contralateral, ACL-healthy knee was found in patients with partial ACL tears (0.8 mm), those with complete ACL tears (1.2 mm), and those who had undergone failed ACL reconstruction (1.7 mm) (p < 0.05). CONCLUSIONS A progressive increase in rotatory knee laxity, defined by side-to-side differences in quantitative pivot shift, was observed in patients with partial ACL tears, those with complete ACL tears, and those who had undergone failed ACL reconstruction. These results may be helpful when assessing outcomes and considering indications for the management of high-grade rotatory knee laxity. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jayson Lian
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Orthopaedic Surgery, Montefiore Medical Center, New York, NY
| | - Theresa Diermeier
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Orthopaedic Sport Medicine, Technical University Munich, Munich, Germany
| | - Mitchell Meghpara
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adam Popchak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Clair N Smith
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Stefano Zaffagnini
- Laboratorio di Biomeccanica e Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Kristian Samuelsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Jón Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - James J Irrgang
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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35
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Diermeier T, Rothrauff BB, Engebretsen L, Lynch AD, Ayeni OR, Paterno MV, Xerogeanes JW, Fu FH, Karlsson J, Musahl V, Svantesson E, Hamrin Senorski E, Rauer T, Meredith SJ. Treatment after anterior cruciate ligament injury: Panther Symposium ACL Treatment Consensus Group. Knee Surg Sports Traumatol Arthrosc 2020; 28:2390-2402. [PMID: 32388664 PMCID: PMC7524809 DOI: 10.1007/s00167-020-06012-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/16/2020] [Indexed: 12/19/2022]
Abstract
Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative vs. non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative vs. non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organizing Committee and Session Chairs for the three working groups. Panel participants reviewed preliminary statements prior to the meeting and provided the initial agreement and comments on the statement via an online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty percent agreement was defined a-priori as consensus. A total of 11 of 13 statements on operative v. non-operative treatment of ACL injury reached the consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and non-operative treatments with patients after an ACL injury.Level of evidence V.
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Affiliation(s)
- Theresa Diermeier
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, 3200 South Water Street, Pittsburgh, PA 15203 USA ,Department of Orthopaedic Sport Medicine, Technical University Munich, Munich, Germany
| | - Benjamin B. Rothrauff
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, 3200 South Water Street, Pittsburgh, PA 15203 USA
| | - Lars Engebretsen
- Department of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Andrew D. Lynch
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, 3200 South Water Street, Pittsburgh, PA 15203 USA
| | - Olufemi R. Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada
| | - Mark V. Paterno
- Division of Sports Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
| | | | - Freddie H. Fu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, 3200 South Water Street, Pittsburgh, PA 15203 USA
| | - Jon Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, 3200 South Water Street, Pittsburgh, PA, 15203, USA.
| | - Eleonor Svantesson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Thomas Rauer
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, 3200 South Water Street, Pittsburgh, PA 15203 USA ,Department of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Sean J. Meredith
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, 3200 South Water Street, Pittsburgh, PA 15203 USA ,Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD USA
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36
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Hughes JD, Rauer T, Gibbs CM, Musahl V. Diagnosis and treatment of rotatory knee instability. J Exp Orthop 2019; 6:48. [PMID: 31865518 PMCID: PMC6925612 DOI: 10.1186/s40634-019-0217-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/13/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Rotatory knee instability is an abnormal, complex three-dimensional motion that can involve pathology of the anteromedial, anterolateral, posteromedial, and posterolateral ligaments, bony alignment, and menisci. To understand the abnormal joint kinematics in rotatory knee instability, a review of the anatomical structures and their graded role in maintaining rotational stability, the importance of concomitant pathologies, as well as the different components of the knee rotation motion will be presented. MAIN BODY The most common instability pattern, anterolateral rotatory knee instability in an anterior cruciate ligament (ACL)-deficient patient, will be discussed in detail. Although intra-articular ACL reconstruction is the gold standard treatment for ACL injury in physically active patients, in some cases current techniques may fail to restore native knee rotatory stability. The wide range of diagnostic options for rotatory knee instability including manual testing, different imaging modalities, static and dynamic measurement, and navigation is outlined. As numerous techniques of extra-articular tenodesis procedures have been described, performed in conjunction with ACL reconstruction, to restore anterolateral knee rotatory stability, a few of these techniques will be described in detail, and discuss the literature concerning their outcome. CONCLUSION In summary, the essence of reducing anterolateral rotatory knee instability begins and ends with a well-done, anatomic ACL reconstruction, which may be performed with consideration of extra-articular tenodesis in a select group of patients.
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Affiliation(s)
- Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA, 15203, USA
| | - Thomas Rauer
- Department of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Christopher M Gibbs
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA, 15203, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA, 15203, USA.
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