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Kemler B, Coladonato C, Perez A, Erickson BJ, Tjoumakaris FP, Freedman KB. Considerations for revision anterior cruciate ligament reconstruction: A review of the current literature. J Orthop 2024; 56:57-62. [PMID: 38784949 PMCID: PMC11109325 DOI: 10.1016/j.jor.2024.05.012] [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: 04/16/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
Background Failure rates among primary Anterior cruciate ligament reconstruction range from 3.2 to 11.1 %. Recently, there has been increased focus on surgical and anatomic considerations which predispose patients to failure, including excessive posterior tibial slope (PTS), unaddressed high-grade pivot shift, and improper tunnel placement. Methods The purpose of this review was to provide a current summary and analysis of the literature regarding patient-related and technical factors surrounding revision ACLR, rehabilitation considerations, overall outcomes, and return to sport (RTS) for patients who undergo revision ACLR. Results In revision ACLR patients, those receiving autografts are 2.78 times less likely to experience a re-rupture compared to patients who receive allografts. Additionally, individuals with properly positioned tunnels and removable implants are considered strong candidates for one-stage revision procedures. Conversely, cases involving primary tunnel widening of approximately 15 mm are typically indicative of two-stage revision ACLR. These findings underscore the importance of graft selection and surgical approach in optimizing outcomes for patients undergoing revision ACLR. Conclusion Given the high rates of revision surgery in young, active patients who return to pivoting sports, the literature recommends strong consideration of a combined ACLR + anterolateral ligament (ALL) or lateral extra-articular tenodesis (LET) procedure in this population. Unrecognized posterolateral corner (PLC) injury is a common cause of ACLR failure and current literature suggests concurrent operative management of high-grade PLC injuries. Excessive PTS has been identified as an independent risk factor for ACL graft failure. Consider revision ACLR with combined slope-reducing tibial osteotomy in cases of posterior tibial slope greater than 12°.
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Affiliation(s)
- Bryson Kemler
- Rothman Orthopaedic Institute at the Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Carlo Coladonato
- Rothman Orthopaedic Institute at the Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Andres Perez
- Rothman Orthopaedic Institute at the Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Brandon J. Erickson
- Rothman Orthopaedic Institute at the Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Fotios P. Tjoumakaris
- Rothman Orthopaedic Institute at the Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Kevin B. Freedman
- Rothman Orthopaedic Institute at the Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
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Kayaalp ME, Apseloff NA, Lott A, Kaarre J, Hughes JD, Ollivier M, Musahl V. Around-the-knee osteotomies part 1: definitions, rationale and planning-state of the art. J ISAKOS 2024; 9:645-657. [PMID: 38460600 DOI: 10.1016/j.jisako.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/11/2024]
Abstract
Knee osteotomies are essential orthopedic procedures with the ability to preserve the joint and correct ligament instabilities. Literature supports the correlation between lower limb malalignment and outcomes after knee ligament reconstruction and cartilage procedures. Concepts such as joint line obliquity, posterior tibial slope angle, and intra-articular deformity correction are integral components of both preoperative planning and postoperative evaluations. The concept of preserving and/or restoring joint line congruence during simultaneous correction of varus or valgus deformity can be achieved through several different approaches. With advancements in osteotomy research and surgical planning technology, the surgical decision-making has increased in complexity. Based upon a patient's specific deformity, decisions need to be made whether to perform a single-level (proximal tibia or distal femur) versus double-level (both proximal tibia and distal femur) osteotomy, and whether to correct deformity in a single plane (coronal or sagittal) or perform a biplanar osteotomy, correcting two of the malalignments in either coronal, sagittal, or axial planes. Osteotomy procedures prioritize safety, reproducibility, precision, and meticulous planning. Equally important is the proactive management of possible complications and the implementation of preventive strategies for complications such as hinge fractures and unintentional changes to alignment in other planes. This review navigates the intricate landscape of lower limb alignment, commencing with foundational definitions and rationale for performing osteotomies, progressing through the planning phase, and addressing the critical aspect of complication prevention, all while looking ahead to anticipate future advancements in this field. However, rotational osteotomies and tibial tubercle osteotomies in isolation or as an adjunct procedure are beyond the scope of this review.
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Affiliation(s)
- M Enes Kayaalp
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA; Department Orthopaedics and Traumatology, Istanbul Kartal Training and Research Hospital, Istanbul, 34865, Turkiye
| | - Nicholas A Apseloff
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA
| | - Ariana Lott
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA
| | - Janina Kaarre
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, 41345, Sweden; Sahlgrenska Sports Medicine Center, Gothenburg, 41345, Sweden
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA
| | - Matthieu Ollivier
- Aix Marseille Univ, CNRS, ISM, Inst Movement Sci, Marseille, 13009, France
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA.
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Kayaalp ME, Winkler P, Zsidai B, Lucidi GA, Runer A, Lott A, Hughes JD, Musahl V. Slope Osteotomies in the Setting of Anterior Cruciate Ligament Deficiency. J Bone Joint Surg Am 2024:00004623-990000000-01164. [PMID: 39066689 DOI: 10.2106/jbjs.23.01352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
➤ Posterior tibial slope (PTS) of ≥12° represents an important risk factor for both anterior cruciate ligament (ACL) injury and ACL reconstruction failure.➤ PTS measurements can significantly differ on the basis of the imaging modality and the measurement technique used. PTS should be measured on strictly lateral radiographs, with a recommended proximal tibial length of 15 cm in the image. The PTS measurement can be made by placing 2 circles to define the proximal tibial axis, 1 just below the tibial tubercle and another 10 cm below it. PTS measurements are underestimated when made on magnetic resonance imaging and computed tomography.➤ Slope-reducing osteotomies can be performed using a (1) supratuberosity, (2) tubercle-reflecting transtuberosity, or (3) infratuberosity method. The correction target remains a topic of debate. Although it is controversial, some authors recommend overcorrecting the tibial slope slightly to a range of 4° to 6°. For instance, if the initial slope is 12°, a correction of 6° to 8° should be performed, given the target tibial slope of 4° to 6°.➤ Clinical outcomes following slope-reducing osteotomies have been favorable. However, potential complications, limited data with regard to the impact of slope-reducing osteotomies on osteoarthritis, and uncertainty with regard to the effects on the patellofemoral joint are notable concerns.➤ Patients with complex deformities may need biplanar osteotomies to comprehensively address the condition.
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Affiliation(s)
- Mahmut Enes Kayaalp
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Orthopaedics and Traumatology, Istanbul Kartal Training and Research Hospital, Istanbul, Turkey
| | - Philipp Winkler
- Department for Orthopaedics and Traumatology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
| | - Balint Zsidai
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
| | - Gian Andrea Lucidi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Armin Runer
- Department of Sports Orthopaedics, Klinikum rechts der Isar Haus, Technical University of Munich, Munich, Germany
| | - Ariana Lott
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania
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Kotiuk V, Ziółek T, Kostrub O, Blonskyi R, Podik V, Smirnov D. Smith machine squats pose high risk to ACL graft integrity after the ACL reconstruction and conventional squats are a safer alternative. Knee Surg Sports Traumatol Arthrosc 2024; 32:1902-1910. [PMID: 38751107 DOI: 10.1002/ksa.12263] [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: 09/25/2023] [Revised: 04/28/2024] [Accepted: 05/02/2024] [Indexed: 07/21/2024]
Abstract
PURPOSE The purpose of this study was to evaluate the impact of squats after the anterior cruciate ligament (ACL) reconstruction on the ACL graft, considering new data on biomechanics, posterior tibial slope (PTS) and anterolateral ligament (ALL). METHODS Utilising finite element analysis on the new 14-component knee joint model, we have evaluated stresses on the knee elements separately for the knee with a native double-bundle ACL and with a single-bundle ACL graft for the 5° and 14° PTS variants during both conventional and Smith machine horizontal squats. RESULTS Replacing a native ACL with a single-bundle graft causes an overstrain on the graft compared to the intact ACL under all conditions. Stresses on the ACL, ACL graft and ALL are much higher during the Smith machine squats compared to the conventional ones. The stress on the menisci is 3.6-4.9 times higher with conventional squats. PTS at the squats' lowest point minimally affects ACL stress but impacts menisci. CONCLUSIONS The single-bundle ACL reconstruction (ACLR) does not reproduce the biomechanics of the native ACL and increases stresses in most knee joint elements, according to the current study. Conventional squats are relatively safe for the ACL graft at their lowest point. Passing the half-squat position is the most dangerous point. Smith machine horizontal squats produce stress on the ACL graft several times higher than its estimated breaking load and dangerous stress levels on the ALL. During the rehabilitation following ACLR, it is advisable to prioritise the conventional squats over Smith machine squats until ligamentisation is complete. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | - Oleksandr Kostrub
- Department of Sports and Ballet Trauma of State Institute of Traumatology and Orthopedics of NAMS of Ukraine, Kyiv, Ukraine
| | - Roman Blonskyi
- Department of Sports and Ballet Trauma of State Institute of Traumatology and Orthopedics of NAMS of Ukraine, Kyiv, Ukraine
| | - Volodymyr Podik
- Department of Sports and Ballet Trauma of State Institute of Traumatology and Orthopedics of NAMS of Ukraine, Kyiv, Ukraine
| | - Dmytro Smirnov
- Department of Sports and Ballet Trauma of State Institute of Traumatology and Orthopedics of NAMS of Ukraine, Kyiv, Ukraine
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Winkler PW, Kayaalp ME, Runer A, Zsidai B, Lucidi GA, Debski RE, Samuelsson K, Musahl V. Biomechanical Analysis of Tibial Motion and ACL Graft Forces After ACLR With and Without LET at Varying Tibial Slopes: Letter to the Editor. Am J Sports Med 2024; 52:NP20-NP21. [PMID: 39101732 DOI: 10.1177/03635465241255604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
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6
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Olson CP, Mabrouk A, Liechti DJ, Tollefson LV, Kennedy NI, LaPrade RF. Inconsistent Return to Sport Despite Improved Outcomes After Re-revision Anterior Cruciate Ligament Reconstruction: An Updated Systematic Review. Arthroscopy 2024; 40:2096-2111. [PMID: 38092276 DOI: 10.1016/j.arthro.2023.12.001] [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: 09/10/2023] [Revised: 11/25/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE To systematically review the literature evaluating patient-reported outcomes and return to sport after re-revision anterior cruciate ligament reconstruction (ACLR) procedures. The secondary objectives were 2-fold: to identify the risk factors that lead to revision ACLR failure and to assess the secondary knee structure injuries after the initial revision ACLR. METHODS A systematic review of the literature was performed using the MEDLINE/PubMed and Cochrane databases. The inclusion criteria were outcomes of re-revision ACLR, minimum of 2 years' follow-up, human studies, and English language. Basic science articles, epidemiologic studies, editorials, surgical technique articles, surveys, cadaveric studies, and animal studies were excluded. RESULTS Fifteen studies met the inclusion criteria and were considered for review. There were 6 Level III and 9 Level IV studies that included 399 patients undergoing re-revision ACLR. The rate of concomitant meniscal lesions at the time of re-revision ranged from 35% to 90%. The prevalence of concomitant cartilaginous lesions at the time of re-revision ranged from 13.6% to 90%. Compared with preoperative scores, patient-reported outcomes overall improved after re-revision ACLR, with mean preoperative Lysholm scores ranging from 38.4 to 73.15 that improved to postoperative scores ranging from 68 to 87.8. However, return to sport at preinjury levels was inconsistent, with rates ranging from 12.5% to 80%. CONCLUSIONS Re-revision ACLR was found to restore knee stability and improve functional outcomes. Despite this improvement, there was a low rate of return to sport at the preinjury level. Functional outcomes were also inferior when compared with primary ACLR. In addition, concomitant knee pathologies were found to rise in prevalence compared with revision and primary ACLR cases. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies.
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Affiliation(s)
- Conner P Olson
- University of Minnesota Medical School, Minneapolis, Minnesota, U.S.A
| | - Ahmed Mabrouk
- Mid Yorkshire Teaching Hospitals, Yorkshire, England, United Kingdom
| | - Daniel J Liechti
- Black Hills Orthopedic & Spine Center of Wyoming, Gillette, Wyoming, U.S.A
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7
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Dadoo S, Benvegnu N, Herman ZJ, Yamamoto T, Hughes JD, Musahl V. Revision Anterior Cruciate Ligament Reconstruction and Associated Procedures. Clin Sports Med 2024; 43:449-464. [PMID: 38811121 DOI: 10.1016/j.csm.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Failure of anterior cruciate ligament reconstruction (ACLR) is a common yet devastating complication due to inferior clinical outcomes associated with revision ACLR. Identifying the cause and associated risk factors for failure is the most important consideration during preoperative planning. Special attention to tunnel quality, concomitant injuries, and modifiable risk factors will help determine the optimal approach and staging for revision ACLR. Additional procedures including lateral extra-articular tenodesis and osteotomy may be considered for at-risk populations. The purpose of this review is to explore causes of ACLR failure, clinical indications and appropriate patient evaluation, and technical considerations when performing revision ACLR.
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Affiliation(s)
- Sahil Dadoo
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203, USA.
| | - Neilen Benvegnu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203, USA
| | - Zachary J Herman
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203, USA
| | - Tetsuya Yamamoto
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203, USA; Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203, USA; 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, 3200 South Water Street, Pittsburgh, PA 15203, USA; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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8
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Vieider RP, Mehl J, Rab P, Brunner M, Schulz P, Rupp MC, Siebenlist S, Hinz M. Malrotated lateral knee radiographs do not allow for a proper assessment of medial or lateral posterior tibial slope. Knee Surg Sports Traumatol Arthrosc 2024; 32:1462-1469. [PMID: 38629758 DOI: 10.1002/ksa.12170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 03/13/2024] [Accepted: 03/20/2024] [Indexed: 05/31/2024]
Abstract
PURPOSE The aim of this study was to investigate whether malrotation of lateral knee radiographs influences posterior tibial slope (PTS) measurements. METHODS Lateral knee radiographs of all patients who underwent knee surgery at a single institution between June 2022 and January 2023 and received multiple lateral knee radiographs were included. Radiographs were categorised as malrotated lateral knee radiographs or lateral knee radiographs based on the radiographic distance between the medial and lateral posterior femoral condyles. Medial PTS (MPTS) and lateral PTS (LPTS) were evaluated on malrotated lateral knee radiographs and lateral knee radiographs and compared using the paired t test. Intra- and interrater reliability between four raters were assessed for MPTS and LPTS measurements. RESULTS A total of 92 lateral knee radiographs (46 pairs of malrotated lateral knee radiographs and lateral knee radiographs; 50.0% right side) from 46 patients (33.2 ± 12.4 years, 69.6% male) were included. Mean posterior femoral condyle distance in malrotated lateral knee radiographs was 8.1 ± 4.4 mm. Overall, MPTS and LPTS were significantly higher on malrotated lateral knee radiographs versus lateral knee radiographs (medial: 10.5 ± 3.2° vs. 9.7 ± 3.5°, p < 0.05; lateral: 10.6 ± 3.4° vs. 9.7 ± 3.3°, p < 0.05). Mean absolute difference between MPTS and LPTS on malrotated lateral knee radiographs versus lateral knee radiographs were |1.9| ± |1.5|° and |2.0| ± |1.8|°, respectively. Intrarater reliability was 'moderate' and interrater reliability was 'good' for both MPTS and LPTS. CONCLUSION Malrotation of lateral knee radiographs led to a significant distortion of both the MPTS and LPTS. In clinical practice, attention should be placed on the (mal)rotation of lateral knee radiographs, especially in patients for whom a slope-correcting osteotomy is being discussed. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Romed P Vieider
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Julian Mehl
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Peter Rab
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Moritz Brunner
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Phillip Schulz
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | | | - Sebastian Siebenlist
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Maximilian Hinz
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
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Sell TC, Zerega R, King V, Reiter CR, Wrona H, Bullock GS, Mills N, Räisänen A, Ledbetter L, Collins GS, Kvist J, Filbay SR, Losciale JM. Anterior Cruciate Ligament Return to Sport after Injury Scale (ACL-RSI) Scores over Time After Anterior Cruciate Ligament Reconstruction: A Systematic Review with Meta-analysis. SPORTS MEDICINE - OPEN 2024; 10:49. [PMID: 38689130 PMCID: PMC11061071 DOI: 10.1186/s40798-024-00712-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 04/02/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Psychological readiness is an important consideration for athletes and clinicians when making return to sport decisions following anterior cruciate ligament reconstruction (ACLR). To improve our understanding of the extent of deficits in psychological readiness, a systematic review is necessary. OBJECTIVE To investigate psychological readiness (measured via the Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI)) over time after ACL tear and understand if time between injury and surgery, age, and sex are associated with ACL-RSI scores. METHODS Seven databases were searched from the earliest date available to March 22, 2022. Articles reporting ACL-RSI scores after ACL tear were included. Risk of bias was assessed using the ROBINS-I, RoB-2, and RoBANS tools based on the study design. Evidence certainty was assessed for each analysis. Random-effects meta-analyses pooled ACL-RSI scores, stratified by time post-injury and based on treatment approach (i.e., early ACLR, delayed ACLR, and unclear approach). RESULTS A total of 83 studies were included in this review (78% high risk of bias). Evidence certainty was 'weak' or 'limited' for all analyses. Overall, ACL-RSI scores were higher at 3 to 6 months post-ACLR (mean = 61.5 [95% confidence interval (CI) 58.6, 64.4], I2 = 94%) compared to pre-ACLR (mean = 44.4 [95% CI 38.2, 50.7], I2 = 98%), remained relatively stable, until they reached the highest point 2 to 5 years after ACLR (mean = 70.7 [95% CI 63.0, 78.5], I2 = 98%). Meta-regression suggests shorter time from injury to surgery, male sex, and older age were associated with higher ACL-RSI scores only 3 to 6 months post-ACLR (heterogeneity explained R2 = 47.6%), and this reduced 1-2 years after ACLR (heterogeneity explained R2 = 27.0%). CONCLUSION Psychological readiness to return to sport appears to improve early after ACL injury, with little subsequent improvement until ≥ 2-years after ACLR. Longer time from injury to surgery, female sex and older age might be negatively related to ACL-RSI scores 12-24 months after ACLR. Due to the weak evidence quality rating and the considerable importance of psychological readiness for long-term outcomes after ACL injury, there is an urgent need for well-designed studies that maximize internal validity and identify additional prognostic factors for psychological readiness at times critical for return to sport decisions. REGISTRATION Open Science Framework (OSF), https://osf.io/2tezs/ .
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Affiliation(s)
- Timothy C Sell
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Ryan Zerega
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Victoria King
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | | | - Hailey Wrona
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Garrett S Bullock
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston Salem, NC, USA
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK
| | - Nilani Mills
- University of New South Wales, Sydney, NSW, Australia
| | - Anu Räisänen
- Department of Physical Therapy Education-Oregon, College of Health Sciences-Northwest, Western University of Health Sciences, Oregon, USA
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Canada
| | | | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Joanna Kvist
- Unit of Physiotherapy, Department of Health, Medicine, and Caring Medicine, University of Linkoping, Linköping, Sweden
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institute, Stockholm, Sweden
| | - Stephanie R Filbay
- Department of Physiotherapy, Centre for Health, Exercise and Sports Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Justin M Losciale
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada.
- Arthritis Research Canada, Vancouver, Canada.
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10
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Kemler B, Coladonato C, Sonnier JH, Campbell MP, Darius D, Erickson BJ, Tjoumakaris FP, Freedman KB. Evaluation of Failed ACL Reconstruction: An Updated Review. Open Access J Sports Med 2024; 15:29-39. [PMID: 38586217 PMCID: PMC10998505 DOI: 10.2147/oajsm.s427332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 03/23/2024] [Indexed: 04/09/2024] Open
Abstract
Failure rates among primary Anterior Cruciate Ligament Reconstruction (ACLR) range from 3.2% to 11.1%. Recently, there has been increased focus on surgical and anatomic considerations which predispose patients to failure, including excessive posterior tibial slope (PTS), unaddressed high-grade pivot shift, and improper tunnel placement. The purpose of this review was to provide a current summary and analysis of the literature regarding patient-related and technical factors surrounding revision ACLR, rehabilitation considerations, overall outcomes and return to sport (RTS) for patients who undergo revision ACLR. There is a convincingly higher re-tear and revision rate in patients who undergo ACLR with allograft than autograft, especially amongst the young, athletic population. Unrecognized Posterior Cruciate Ligament (PLC) injury is a common cause of ACLR failure and current literature suggests concurrent operative management of high-grade PLC injuries. Given the high rates of revision surgery in young active patients who return to pivoting sports, the authors recommend strong consideration of a combined ACLR + Anterolateral Ligament (ALL) or Lateral extra-articular tenodesis (LET) procedure in this population. Excessive PTS has been identified as an independent risk factor for ACL graft failure. Careful consideration of patient-specific factors such as age and activity level may influence the success of ACL reconstruction. Additional technical considerations including graft choice and fixation method, tunnel position, evaluation of concomitant posterolateral corner and high-grade pivot shift injuries, and the role of excessive posterior tibial slope may play a significant role in preventing failure.
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Affiliation(s)
- Bryson Kemler
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Carlo Coladonato
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | | | - Michael P Campbell
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Danielle Darius
- Department of Education, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Brandon J Erickson
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | | | - Kevin B Freedman
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
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11
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Dzidzishvili L, Allende F, Allahabadi S, Mowers CC, Cotter EJ, Chahla J. Increased Posterior Tibial Slope Is Associated With Increased Risk of Meniscal Root Tears: A Systematic Review. Am J Sports Med 2024:3635465231225981. [PMID: 38362610 DOI: 10.1177/03635465231225981] [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] [Indexed: 02/17/2024]
Abstract
BACKGROUND While increased posterior tibial slope (PTS) is an established risk factor for anterior cruciate ligament tears, the association between tibial slope and meniscal posterior root tears is not well-defined. PURPOSE To summarize the available literature evaluating the association between PTS and meniscus root injuries compared with patients without root tears. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A literature search was performed using the Scopus, PubMed, and Embase databases. Human clinical studies evaluating the associations between the medial tibial slope (MTS), lateral tibial slope (LTS), lateral-to-medial (L-to-M) slope asymmetry, and the risk of meniscus root tears were included. Patients with medial meniscus posterior root tears (MMPRTs) and lateral meniscus posterior root tears (LMPRTs) were compared with a control group without root injury. Study quality was assessed using the methodological index for non-randomized studies criteria. RESULTS Ten studies with 1313 patients were included (884 patients with root tears; 429 controls). The LMPRT subgroup (n = 284) had a significantly greater LTS (mean ± SD, 7.3°± 1.5° vs 5.7°± 3.91°; P < .001), MTS (5.26°± 1.2° vs 4.8°± 1.25°; P < .001), and increased L-to-M asymmetry (2.3°± 1.3° vs 0.65°± 0.5°; P < .001) compared with controls. The MMPRT group (n = 600) had significantly increased MTS relative to controls (8.1°± 2.5° vs 4.3°± 0.7°; P < .001). Furthermore, there was a higher incidence of noncontact injuries (79.3%) and concomitant ramp lesions (56%) reported in patients with LMPRT. CONCLUSION Increased MTS, LTS, and L-to-M slope asymmetry are associated with an increased risk of LMPRTs, while increased MTS is associated with MMPRTs. Surgeons should consider how proximal tibial anatomy increases the risk of meniscus root injury.
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Affiliation(s)
- Lika Dzidzishvili
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
- Midwest Orthopaedics at Rush, Chicago, Illinois, USA
| | - Felicitas Allende
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
- Midwest Orthopaedics at Rush, Chicago, Illinois, USA
| | - Sachin Allahabadi
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
- Midwest Orthopaedics at Rush, Chicago, Illinois, USA
| | - Colton C Mowers
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
- Midwest Orthopaedics at Rush, Chicago, Illinois, USA
| | - Eric J Cotter
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
- Midwest Orthopaedics at Rush, Chicago, Illinois, USA
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
- Midwest Orthopaedics at Rush, Chicago, Illinois, USA
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Vivacqua TA, Winkler PW, Lucidi GA, Firth AD, Musahl V, Getgood A. Lateral Extra-articular Tenodesis Does Not Decrease Graft Failure in Revision Anterior Cruciate Ligament Reconstruction When Combined With Quadriceps or Patellar Tendon Grafts. Arthroscopy 2024:S0749-8063(24)00090-2. [PMID: 38331366 DOI: 10.1016/j.arthro.2024.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 01/21/2024] [Accepted: 01/25/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE To compare return-to-sport (RTS) rates, graft failure rates, and clinical outcomes in patients who underwent revision anterior cruciate ligament reconstruction (R-ACLR) with additional lateral extra-articular tenodesis (LET) versus isolated R-ACLR. METHODS A retrospective review of the medical records of patients who underwent R-ACLR with or without a modified Lemaire LET procedure was performed. Seventy-four patients with at least 2 years of follow-up who had high-grade positive pivot-shift test findings were included. Concomitant procedures such as meniscectomy and meniscal repair were collected, along with any complications and/or graft failure. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee Subjective Knee Form score were collected. The ability to RTS was defined as fully, partially, or not returned. RESULTS Of the patients, 39 underwent isolated R-ACLR (mean age ± standard deviation, 29.2 ± 12.2 years) whereas 35 underwent an additional LET procedure (mean age, 24.6 ± 7.4 years). The mean length of follow-up in the R-ACLR group was 56.6 ± 26.5 months compared with 44.3 ± 17.6 months in the R-ACLR-LET group (P = .02) (range, 24-120 months). Patient-reported outcome measures were higher in the R-ACLR-LET group, with the KOOS Activities of Daily Living (93.5 ± 2.0 vs 97.2 ± 1.6, P = .03) and KOOS Sport (63.0 ± 3.6 vs 74.3 ± 3.8, P = .05) subdomain scores reaching the level of statistical significance. No differences were found in the other KOOS subdomain scores or the International Knee Documentation Committee scores. Failure rates were not significantly different between the groups (12.8% for R-ACLR vs 11.4% for R-ACLR-LET, P = .99). There were 13 patients (72.2%) in the R-ACLR group and 14 patients (60.8%) in the R-ACLR-LET group who did not RTS. CONCLUSIONS R-ACLR with additional LET showed similar failure and RTS rates to isolated R-ACLR after failed ACLR. The R-ACLR-LET group showed better functional results with significantly higher KOOS subdomain scores for activities of daily living, as well as sports and recreation. However, this study was unable to recommend the modified Lemaire LET procedure to be routinely used in R-ACLR patients. LEVEL OF EVIDENCE Level III, retrospective comparative therapeutic trial.
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Affiliation(s)
- Thiago Alberto Vivacqua
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada
| | - Philipp W Winkler
- Department of Orthopaedics and Traumatology, Kepler University Hospital Linz, Linz, Austria; Department of Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany; Department of Orthopedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Gian Andrea Lucidi
- Department of Orthopedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Andrew D Firth
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada
| | - Volker Musahl
- Department of Orthopedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Alan Getgood
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada.
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Mehl J, Siebenlist S. [Influence of the bony alignment on the ligaments of the knee joint]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:27-34. [PMID: 37610469 DOI: 10.1007/s00113-023-01363-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 08/24/2023]
Abstract
In recent years biomechanical and clinical studies have shown that the three-dimensional bony alignment of the lower extremities has a relevant influence on the ligamentous structures of the knee and consequently on the stability of the knee joint. Therefore, in the case of pathological ligamentous damage of the knee joint, a possible malalignment must always be thoroughly evaluated and if necessary, included in the treatment planning. Varus malalignment plays an important role especially with respect to the cruciate ligaments as well as the posterolateral ligamentous structures and has been identified as a significant risk factor for failure after surgical reconstruction of these ligamentous structures. Similar data have also been published for valgus malalignment particularly with respect to its negative influence on the anterior cruciate ligament and the medial capsuloligamentous complex. Alignment deviations in the sagittal plane, especially the inclination of the tibial articular surface (slope), have been extensively investigated in several recent studies. It has been demonstrated that the tibial slope has a relevant influence on the anteroposterior stability of the knee joint and hence on the cruciate ligaments. First clinical studies on the surgical correction of the axis in selected patients showed very promising results with the potential of protecting ligament reconstructions against repeated failure; however, further data especially regarding the importance and the exact indications for an additional alignment correction are necessary.
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Affiliation(s)
- Julian Mehl
- Sektion Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - Sebastian Siebenlist
- Sektion Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
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Hinz M, Brunner M, Winkler PW, Sanchez Carbonel JF, Fritsch L, Vieider RP, Siebenlist S, Mehl J. The Posterior Tibial Slope Is Not Associated With Graft Failure and Functional Outcomes After Anatomic Primary Isolated Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2023; 51:3670-3676. [PMID: 37975492 PMCID: PMC10691292 DOI: 10.1177/03635465231209310] [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: 02/20/2023] [Accepted: 09/06/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Biomechanical studies have shown that an increased medial posterior tibial slope (MPTS) may affect anteroposterior knee laxity and tibial shear forces, ultimately increasing the risk for graft failure after anterior cruciate ligament (ACL) reconstruction. Previous clinical studies have, however, reported inconclusive results. PURPOSE The purpose of this study was to evaluate the relationship between the MPTS and graft failure as well as functional outcomes after anatomic primary isolated ACL reconstruction using a hamstring tendon autograft. It was hypothesized that an increased MPTS would be associated with a higher ACL graft failure rate. Furthermore, a higher MPTS would negatively correlate with functional outcomes in patients without ACL graft failure. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Consecutive patients who underwent isolated primary ACL reconstruction with an anteromedial portal drilling technique between January 2011 and December 2019 were retrospectively reviewed. The MPTS was measured on preoperative lateral knee radiographs. At a minimum of 24 months postoperatively, the ACL graft failure rate and patient-reported outcome measures (PROM; International Knee Documentation Committee subjective knee form, Lysholm score, Tegner Activity Scale, visual analog scale for pain and subjective instability) were evaluated. Differences in the MPTS between patients with and without ACL graft failure as well as the frequency of graft failure between those with an MPTS <12° and those with an MPTS ≥12° were assessed for statistical significance. Binary logistic regression analysis was performed to stratify the risk of graft failure with the following variables: MPTS, age at surgery, and sex. Correlation analysis was performed to evaluate the relationship between the MPTS and PROM in patients without ACL graft failure. RESULTS In total, 326 patients were included (median follow-up, 71.0 months [IQR, 49.0-104.0 months]). There was no significant difference in the MPTS between patients with and without graft failure (10.6°± 3.2° vs 11.2°± 2.8°, respectively; P = .264). Additionally, there was no significant difference in the frequency of graft failure between patients with an MPTS <12° and those with an MPTS ≥12° (15.6% vs 16.5%, respectively; P = .835). Binary logistic regression showed that younger age at the time of surgery (odds ratio, 1.069 [95% CI, 1.031-1.109]) was associated with graft failure; sex and MPTS were not associated with graft failure. In patients without ACL graft failure, there was no significant correlation between the MPTS and PROM. CONCLUSION In patients who underwent anatomic primary isolated ACL reconstruction, an increased MPTS was not associated with a higher rate of graft failure or inferior functional outcomes. Younger age was a significant nonmodifiable risk factor for ACL graft failure.
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Affiliation(s)
- Maximilian Hinz
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Moritz Brunner
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Philipp W. Winkler
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
- Department of Orthopaedics and Traumatology, Kepler University Hospital, Linz, Austria
| | | | - Lorenz Fritsch
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Romed P. Vieider
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Sebastian Siebenlist
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Julian Mehl
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
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15
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Kaarre J, Herman ZJ, Grassi A, Hamrin Senorski E, Musahl V, Samuelsson K. Comparison of Improvement in Patient-Reported Knee Function After Revision and Multiple-Revision ACL Reconstruction Compared With Primary ACL Reconstruction. Orthop J Sports Med 2023; 11:23259671231217725. [PMID: 38145220 PMCID: PMC10748942 DOI: 10.1177/23259671231217725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 09/29/2023] [Indexed: 12/26/2023] Open
Abstract
Background Graft failure after anterior cruciate ligament reconstruction (ACLR) is a debilitating complication often requiring revision surgery. It is widely agreed upon that functional knee outcomes after revision ACLR (r-ACLR) are inferior compared with those after primary reconstruction. However, data are scarce on outcomes after multiple-revision ACLR (mr-ACLR). Purpose To compare patient-reported knee function in terms of Knee injury and Osteoarthritis Outcome Score (KOOS) preoperatively and 1-year postoperatively after primary ACLR, r-ACLR, and mr-ACLR and evaluate the pre- to postoperative improvement in KOOS scores for each procedure. Study Design Cohort study; Level of evidence, 3. Methods Patients from the Swedish National Knee Ligament Registry who underwent their index ACLR between 2005 and 2020 with a minimum age of 15 years at the time of surgery were included in this study. All patients had pre- and postoperative KOOS data. The 1-year postoperative KOOS and the pre- to postoperative changes in KOOS were assessed between patients who underwent primary ACLR and those who underwent subsequent r-ACLR and mr-ACLR. Results Of 20,542 included patients, 19,769 (96.2%) underwent primary ACLR, 760 (3.7%) underwent r-ACLR, and 13 (0.06%) underwent mr-ACLR. Patients who underwent r-ACLR had significantly smaller pre- to postoperative changes on all KOOS subscales compared with patients undergoing primary ACLR (P < .0001 for all). Furthermore, patients in the mr-ACLR group had significantly smaller changes in the KOOS-Pain subscale compared with patients in the r-ACLR group (-9 ± 23.3 vs 2.5 ± 18; P = .024). Conclusion The study results indicated that while improvement is seen after primary ACLR, r-ACLR, and mr-ACLR, the greatest improvement in functional outcomes is observed after primary ACLR. Patients who underwent at least 1 r-ACLR, specifically mr-ACLR, had lower postoperative outcome scores, indicating that primary ACLR may provide the best chance for recovery after ACL injury.
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Affiliation(s)
- Janina Kaarre
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Zachary J. Herman
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alberto Grassi
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Eric Hamrin Senorski
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
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16
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Aldag L, Dallman J, Henkelman E, Herda A, Randall J, Tarakemeh A, Morey T, Vopat BG. Various Definitions of Failure Are Used in Studies of Patients Who Underwent Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2023; 5:100801. [PMID: 37766857 PMCID: PMC10520319 DOI: 10.1016/j.asmr.2023.100801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 08/10/2023] [Indexed: 09/29/2023] Open
Abstract
Purpose To conduct a literature review to assess the definitions of anterior cruciate ligament reconstruction (ACLR) failure used throughout the orthopaedic literature. Methods A systematic search of Embase, Ovid Medline, SPORTDiscus, and Web of Science was conducted by a university librarian to identity level I-IV clinical studies on ACLR failure. Inclusion criteria consisted of patients who underwent ACLR and included a definition of failure of ACLR. Patients who underwent anterior cruciate ligament (ACL) repairs, animal/cadaver studies, review studies, non-English language articles, and non-full text articles were excluded. Failure data were extracted from each study and categorized. Other data that were extracted included follow-up time after ACLR, failure reoperation rate, and failure reoperation procedure. Descriptive statistics was used to analyze the data. Results Out of 2,775 studies, 104 (3.75%) met inclusion criteria and were analyzed in this review. The most common definition of ACLR failure included the use of a physical examination, specifically Lachman's test (21/104 [20.2%]), anterior laxity assessment, or a Pivot-Shift test (24/104 [35.2%]) or undergoing or requiring revision ACLR (39/104 [37.5%]). Although some studies used quantitative tests or imaging to help define "failure," others simply defined it as graft rerupture that was otherwise not defined (22/104 [22.5%]). Other common definitions included: the use of imaging (magnetic resonance imaging/radiographs) to confirm graft re-rupture (37/104 [35.6%]), patient-reported outcomes (recurrent instability)/patient reported outcomes measures (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Tegner) (18/104 [17.3%]), and the use of an arthrometer (KT-1000/2000, Rollimeter, or Kneelax) (17/104 [16.3%]). The least common definitions included graft failure or rerupture confirmed by arthroscopy (13/104 [12.5%]) and nonrevision surgery (2/104 [1.0%]). The failure rate of this procedure ranged from 0% to 100% depending on the definition of "failure." Conclusion In this study, we found that a variety of definitions of failure are used among studies published in the orthopaedic literature. The most common criteria for failure of ACLR were the results of physical examination tests (35%), the need for undergoing a revision ACLR (36%), and the use of imaging to diagnose the failure (34%). About 17% of studies included in this review used patient-reported outcomes, specifically recurrent instability, or PROMs (IKDC, KOOS, Tegner) in their assessment of failure of ACLR. The least used definitions of "failure" of ACLR included nonrevision ACLR surgery (2%). Although some studies used similar tests or categories in their definition of failure, there were a variety of score and grade cutoff points between them. Level of Evidence Level IV, systematic review of Level II-IV studies.
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Affiliation(s)
- Levi Aldag
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Johnathan Dallman
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Erik Henkelman
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Ashley Herda
- Department of Health, Sport, and Exercise Sciences, University of Kansas, Lawrence, Kansas, U.S.A
| | - Jeffrey Randall
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Armin Tarakemeh
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Tucker Morey
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Bryan G. Vopat
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
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Dejour D, Rozinthe A, Demey G. First revision ACL reconstruction combined with tibial deflexion osteotomy improves clinical scores at 2 to 7 years follow-up. Knee Surg Sports Traumatol Arthrosc 2023; 31:4467-4473. [PMID: 37515616 DOI: 10.1007/s00167-023-07493-x] [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: 03/22/2023] [Accepted: 06/12/2023] [Indexed: 07/31/2023]
Abstract
PURPOSE To report outcomes of first revision anterior cruciate ligament reconstruction (ACLR) with tibial deflexion osteotomy (TDO) in patients with posterior tibial slope (PTS) >10° at >2 years. METHODS The authors studied outcomes of a consecutive series of 16 patients that underwent first revision ACLR with TDO, including Lysholm score, IKDC subjective and objective scores, Lachman test, PTS, and signs of osteoarthritis. One woman was excluded because of early signs of knee arthritis, as the first revision ACLR took place 27 years following the primary ACLR. This left a final cohort of 15 patients assessed at minimum follow-up of 2 years. RESULTS The final cohort comprised 14 men and 1 woman aged 25.3 ± 6.6 years (range 16-39) at first revision ACLR. At final follow-up of 4.4 ± 1.5 years (range, 2-7), PTS was corrected from 12.5 ± 1.8° (range 8-15°) to 1.9 ± 3.6° (range - 4 to 8°), and none of the knees had radiographic signs of osteoarthritis. Lysholm score was 83.8±12.5, IKDC subjective score was 80.3±16.2, and IKDC objective score was A in 5 (33%), and B in 10 (67%). The net improvement exceeded the minimal clinically important difference (MCID) in 93% of patients for the IKDC subjective score and in 80% of patients for the Lysholm score. None of the knees had any retears, and only one required a reoperation to re-suture a medial meniscal tear due to trauma. CONCLUSION At 2-7 years following revision ACLR combined with TDO, net improvement exceeded the MCID in 93% of patients for IKDC subjective score and in 80% of patients for Lysholm score, with no retears or major complications. These results suggest that TDO is a safe technique to protect the ACL graft and might be considered as of first revision ACLR to correct excessive PTS. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- David Dejour
- Ramsay Santé, Lyon-Ortho-Clinic, Clinique de La Sauvegarde, Lyon, France
| | - Anouk Rozinthe
- Ramsay Santé, Lyon-Ortho-Clinic, Clinique de La Sauvegarde, Lyon, France
| | - Guillaume Demey
- Ramsay Santé, Lyon-Ortho-Clinic, Clinique de La Sauvegarde, Lyon, France
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Özbek EA, Winkler PW, Nazzal EM, Zsidai B, Drain NP, Kaarre J, Sprague A, Lesniak BP, Musahl V. Failure Rates and Complications After Multiple-Revision ACL Reconstruction: Comparison of the Over-the-Top and Transportal Drilling Techniques. Orthop J Sports Med 2023; 11:23259671231186972. [PMID: 37533497 PMCID: PMC10392383 DOI: 10.1177/23259671231186972] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/14/2023] [Indexed: 08/04/2023] Open
Abstract
Background Multiple-revision anterior cruciate ligament reconstruction (ACLR) presents several technical challenges, often due to residual hardware, tunnel widening, malposition, or staged surgeries. Purpose To compare failure and complication rates between the over-the-top (OTT) and transportal drilling (TD) techniques in patients undergoing surgery for failed revision ACLR. Study Design Cohort study; Level of evidence, 3. Methods The medical records of patients with at least 2 revision ACLRs using either the OTT or TD technique were reviewed retrospectively. Data on patient demographics, graft characteristics, number of revisions, concomitant procedures, complications, and failures were collected. Between-group comparisons of continuous and categorical variables were conducted with the independent-samples t test and the Fisher exact or chi-square test, respectively. Results A total of 101 patients undergoing multiple-revision ACLR with OTT (n = 37, 37%) and TD (n = 64, 63%) techniques were included for analysis. The mean follow-up time was 60 months (range, 12-196 months). There were no significant differences in age, sex, body mass index, laterality, or follow-up length between groups (P > .05). Allograft was the graft used most frequently (n = 64; 67.3%) with no significant differences between groups in graft diameter (P > .05). There were no statistically significant differences between groups regarding rate of concurrent medial and lateral meniscus, cartilage, or lateral extra-articular procedures (P > .05). There was also no significant66 between-group difference in complication rate (OTT: n = 2 [5.4%]; TD: n = 8 [13%]) or graft failure rate (OTT: n = 4 [11%]; TD: n = 14 [22%]) (P > .05 for both). Conclusion The results of this study showed notably high failure and complication rates in challenging multiple-revision ACLR. Complication and failure rates were similar between techniques, demonstrating that the OTT technique is a valuable alternative that can be used in a revision ACLR, particularly as a single-stage approach when the single-stage TD technique is not possible.
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Affiliation(s)
- Emre Anil Özbek
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey
| | - Philipp W. Winkler
- Department for Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Orthopaedics and Traumatology, Kepler University Hospital Linz, Linz, Austria
| | - Ehab M. Nazzal
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bálint Zsidai
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nicholas P. Drain
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Janina Kaarre
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Andrew Sprague
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bryson P. Lesniak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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19
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Runer A, Keeling L, Wagala N, Nugraha H, Özbek EA, Hughes JD, Musahl V. Current trends in graft choice for primary anterior cruciate ligament reconstruction - part II: In-vivo kinematics, patient reported outcomes, re-rupture rates, strength recovery, return to sports and complications. J Exp Orthop 2023; 10:40. [PMID: 37014518 PMCID: PMC10073382 DOI: 10.1186/s40634-023-00601-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/22/2023] [Indexed: 04/05/2023] Open
Abstract
Postoperative patient satisfaction after anterior cruciate ligament reconstruction (ACL-R) is influenced mainly by the degree of pain, the need for reoperation, and functional performance in daily activities and sports. Graft choice has shown to have an influence on postoperative outcomes after ACL-R. While patient reported outcomes measurements do not differ between graft options, evidence shows that normal knee kinematics is not fully restored after ACL-R with an increase in postoperative anterior tibial translation (ATT). Postoperative graft rupture rates seem to favor bone-patella-tendon-bone (BPTB) and quadriceps tendon (QT) autografts over HT or allografts. While return to sports rates seem comparable between different graft types, postoperative extensor strength is reduced in patients with BPTB and QT whereas flexion strength is weakened in patients with HT. Postoperative donor site morbidity is highest in BPTB but comparable between HT and QT. With all graft options having advantages and drawbacks, graft choice must be individualized and chosen in accordance with the patient.
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Affiliation(s)
- Armin Runer
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA.
- Department for Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Laura Keeling
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nyaluma Wagala
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hans Nugraha
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University of Udayana, / Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | - Emre Anil Özbek
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- 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, Pittsburgh, PA, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Duerr RA, Ormseth B, DiBartola A, Geers K, Kaeding CC, Siston R, Flanigan DC, Magnussen RA. Association of Elevated Posterior Tibial Slope With Revision Anterior Cruciate Ligament Graft Failure in a Matched Cohort Analysis. Am J Sports Med 2023; 51:38-48. [PMID: 36412535 DOI: 10.1177/03635465221134806] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Elevated posterior tibial slope (PTS) has been identified as an important risk factor in anterior cruciate ligament (ACL) injuries and ACL graft failures. The cutoff value to recommend treatment with slope-reducing osteotomy remains unclear and is based on expert opinion and small case series. PURPOSE (1) To determine whether there is a difference in PTS shown on lateral knee radiographs and magnetic resonance imaging (MRI) scans in a group of patients who experienced revision ACL graft failure versus a control group of patients who underwent successful revision ACL reconstruction, (2) to identify cutoff values of PTS measurements that predict risk of revision ACL graft failure, and (3) to examine whether there is a correlation between radiographic and MRI measurements of PTS. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS A total of 38 patients who experienced revision ACL graft failure were identified from a revision ACL database. These patients were matched 1:1 by age, sex, and graft type to a group of 38 control patients who underwent revision ACL reconstruction with no evidence of graft failure at a minimum 2 years of follow-up. Medial and lateral PTS were measured by lateral knee radiographs and MRI scans of the affected limb. Demographics, surgical characteristics, and PTS were compared between the groups. The optimal cutoff values of medial and lateral PTS per radiographs and MRI scans for predicting increased risk of revision ACL graft failure were determined by receiver operating characteristic curves. Conditional multivariable logistic regression was used to assess the relative contribution of PTS cutoff values as a predictor of revision graft failure. RESULTS The mean PTS values in the failure group were significantly higher than those in the control group on radiographs (medial, 13.2°± 2.9° vs 10.3°± 2.9°; P < .001; lateral, 12.9°± 3.0° vs 9.8°± 2.8°; P < .001) and MRI scans (medial, 7.2°± 3.1° vs 4.8°± 2.9°; P < .001; lateral, 8.4 ± 3.1° vs 5.9 ± 3.0°; P < .001). A radiographic medial PTS ≥14° had the highest increased risk of revision ACL graft failure with sensitivity equal to 50% and specificity to 92.1% (odds ratio, 18.71; 95% CI, 2.0-174.9; P = .01). CONCLUSION Elevated PTS was a significant risk factor for revision ACL graft failure. Patients with radiographic medial PTS ≥14° had 18.7-times increased risk of revision ACL failure.
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Affiliation(s)
- Robert A Duerr
- Department of Orthopedic Surgery, Mercy Clinic Sports Medicine, St. Louis, Missouri, USA
| | - Benjamin Ormseth
- Jameson Crane Sports Medicine Institute, Department of Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alex DiBartola
- Jameson Crane Sports Medicine Institute, Department of Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Katie Geers
- Department of Mechanical and Aerospace Engineering, The Ohio State University, Columbus, Ohio, USA. Presented at the annual meeting of the AOSSM, Nashville, Tennessee, July 2021
| | - Christopher C Kaeding
- Jameson Crane Sports Medicine Institute, Department of Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Robert Siston
- Department of Mechanical and Aerospace Engineering, The Ohio State University, Columbus, Ohio, USA. Presented at the annual meeting of the AOSSM, Nashville, Tennessee, July 2021
| | - David C Flanigan
- Jameson Crane Sports Medicine Institute, Department of Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Robert A Magnussen
- Jameson Crane Sports Medicine Institute, Department of Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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21
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Vieider RP, Berthold DP, Runer A, Winkler PW, Schulz P, Rupp MC, Siebenlist S, Muench LN. The 50 most cited studies on posterior tibial slope in joint preserving knee surgery. J Exp Orthop 2022; 9:119. [PMID: 36508044 PMCID: PMC9743935 DOI: 10.1186/s40634-022-00557-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To determine the 50 most cited studies on posterior tibial slope (PTS) in joint preserving knee surgery and assess their level of evidence, objective study quality scores as well as to examine whether the study quality correlated with the citation count and citation density in the top 50 list. METHODS A literature search on Web of Science was performed to determine the 50 most cited studies on the topic of PTS in joint preserving knee surgery between 1990 and 2022. The studies were evaluated for their bibliographic parameters, level of evidence rating (LOE), citation counts, the Modified Coleman Methodological Score (MCMS), the Methodological Index for Non-Randomized Studies (MINORS), and the Radiologic Methodology and Quality Scale (MQCSRE). RESULTS Of the top 50 list, 16 studies were published in the American Journal of Sports Medicine. A total of 23 studies were produced in the United States (46%). Of 10 different study types, case control studies (n = 16, 32%) and cadaveric studies (n = 10, 20%) were most common. 15 studies (30%) were purely radiological studies. 6 studies were level II (12%), 23 level III (46%), 15 level IV (30%), and 6 level V studies (12%), respectively. The number of citations ranged from 42 to 447 (mean 105.6 ± 79.2 citations) and showed a mean citation density of 10.3 ± 5.2, composed of the decades 1994 - 2000 (8.3 ± 4.1), 2001 - 2010 (11.1 ± 5.9), 2011 - 2019 (10.1 ± 5.1). Mean quality scores were 55.9 ± 13.0 for MCMS (n = 18), 14.5 ± 3.2 for MINORS (n = 18) and 18.1 ± 3.7 for MQCSRE (n = 20), respectively. High citation counts did not correlate with higher study quality scores (p > 0.05). Radiological studies were not significantly cited more often than non-radiological studies (mean 116.9 ± 88.3 vs. 100.8 ± 75.8 citations; p > 0.05). CONCLUSION In joint preserving knee surgery, the 50 most cited studies on PTS did not represent a ranking of the highest methodological quality scores. Citation counts and citation density over the past three decades did not significantly differ, even though the number of articles in the presented list multiplied over the same period. This list can serve as a reference tool for orthopedic surgeons aiming to review PTS literature.
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Affiliation(s)
- Romed P. Vieider
- grid.5252.00000 0004 1936 973XDepartment of Sports Orthopaedics, Klinikum Rechts Der Isar, Technichal University of Munich, Ismaninger Str. 22, 81675 Munich, Germany ,grid.22937.3d0000 0000 9259 8492Medical University of Vienna, Spitalgasse 23, Vienna, Austria
| | - Daniel P. Berthold
- grid.5252.00000 0004 1936 973XDepartment of Sports Orthopaedics, Klinikum Rechts Der Isar, Technichal University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Armin Runer
- grid.5252.00000 0004 1936 973XDepartment of Sports Orthopaedics, Klinikum Rechts Der Isar, Technichal University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Philipp W. Winkler
- grid.5252.00000 0004 1936 973XDepartment of Sports Orthopaedics, Klinikum Rechts Der Isar, Technichal University of Munich, Ismaninger Str. 22, 81675 Munich, Germany ,grid.473675.4Department of Orthopaedics and Traumatology, Kepler University Hospital GmbH, Linz, Austria
| | - Phillip Schulz
- grid.5252.00000 0004 1936 973XDepartment of Sports Orthopaedics, Klinikum Rechts Der Isar, Technichal University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Marco-Christopher Rupp
- grid.5252.00000 0004 1936 973XDepartment of Sports Orthopaedics, Klinikum Rechts Der Isar, Technichal University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Sebastian Siebenlist
- grid.5252.00000 0004 1936 973XDepartment of Sports Orthopaedics, Klinikum Rechts Der Isar, Technichal University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Lukas N. Muench
- grid.5252.00000 0004 1936 973XDepartment of Sports Orthopaedics, Klinikum Rechts Der Isar, Technichal University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
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22
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Winkler PW, Chan CK, Lucidi GA, Polamalu SK, Wagala NN, Hughes JD, Debski RE, Musahl V. Increasing the posterior tibial slope lowers in situ forces in the native ACL primarily at deep flexion angles. J Orthop Res 2022. [PMID: 36370132 DOI: 10.1002/jor.25484] [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: 06/14/2022] [Revised: 10/03/2022] [Accepted: 11/07/2022] [Indexed: 11/15/2022]
Abstract
High tibial osteotomy is becoming increasingly popular but can be associated with unintentional posterior tibial slope (PTS) increase and subsequent anterior cruciate ligament (ACL) degeneration. This study quantified the effect of increasing PTS on knee kinematics and in situ forces in the native ACL. A robotic testing system was used to apply external loads from full extension to 90° flexion to seven human cadaveric knees: (1) 200 N axial compressive load, (2) 5 Nm internal tibial + 10 Nm valgus torque, and (3) 5 Nm external tibial + 10 Nm varus torque. Kinematics and in situ forces in the ACL were acquired for the native and increased PTS state. Increasing PTS resulted in increased anterior tibial translation at 30° (1.8 mm), 60° (1.7 mm), and 90° (0.9 mm) flexion and reduced in situ force in the ACL at 30° (57.6%), 60° (69.8%), and 90° (75.0%) flexion in response to 200 N axial compressive load. In response to 5 Nm internal tibial + 10 Nm valgus torque, there was significantly less (39.0%) in situ force in the ACL at 90° flexion in the increased compared with the native PTS state. Significantly less in situ force in the ACL at 60° (62.8%) and 90° (67.0%) flexion was observed in the increased compared with the native PTS state in response to 5 Nm external tibial + 10 Nm varus torque. Increasing PTS affects knee kinematics and results in a reduction of in situ forces in the native ACL during compressive and rotatory loads at flexion angles exceeding 30°. In a controlled laboratory setting PTS increase unloads the ACL, affecting its natural function.
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Affiliation(s)
- Philipp W Winkler
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Sports Orthopaedics, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Calvin K Chan
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gian Andrea Lucidi
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sene K Polamalu
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nyaluma N Wagala
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan D Hughes
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedics, University of Gothenburg, Gothenburg, Sweden
| | - Richard E Debski
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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23
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Low posterior tibial slope is associated with increased risk of PCL graft failure. Knee Surg Sports Traumatol Arthrosc 2022; 30:3277-3286. [PMID: 35028674 DOI: 10.1007/s00167-021-06760-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 09/27/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate the effect of posterior tibial slope (PTS) on patient-reported outcomes (PROs) and posterior cruciate ligament (PCL) graft failure after PCL reconstruction. METHODS Patients undergoing PCL reconstruction with a minimum 2-year follow-up were included in this retrospective cohort study. A chart review was performed to collect patient-, injury-, and surgery-related data. Medial PTS was measured on preoperative lateral radiographs. Validated PROs, including the International Knee Documentation Committee Subjective Knee Form, Knee injury and Osteoarthritis Outcome Score, Lysholm Score, Tegner Activity Scale, and Visual Analogue Scale for pain, were collected at final follow-up. A correlation analysis was conducted to assess the relationship between PTS and PROs. A logistic regression model was performed to evaluate if PTS could predict PCL graft failure. RESULTS Overall, 79 patients with a mean age of 28.6 ± 11.7 years and a mean follow-up of 5.7 ± 3.3 years were included. After a median time from injury of 4.0 months, isolated and combined PCL reconstruction was performed in 22 (28%) and 57 (72%) patients, respectively. There were no statistically significant differences in PROs and PTS between patients undergoing isolated and combined PCL reconstruction (non-significant [n.s.]). There were no significant correlations between PTS and PROs (n.s.). In total, 14 (18%) patients experienced PCL graft failure after a median time of 17.5 months following PCL reconstruction. Patients with PCL graft failure were found to have statistically significantly lower PTS than patients without graft failure (7.0 ± 2.3° vs. 9.2 ± 3.3°, p < 0.05), while no differences were found in PROs (n.s.). PTS was shown to be a significant predictor of PCL graft failure, with a 1.3-fold increase in the odds of graft failure for each one-degree reduction in PTS (p < 0.05). CONCLUSIONS This study showed that PTS does not affect PROs after PCL reconstruction, but that PTS represents a surgically modifiable predictor of PCL graft failure. LEVEL OF EVIDENCE III.
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24
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[Research progress of anterior cruciate ligament reconstruction with over-the-top technique]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:1166-1171. [PMID: 36111481 PMCID: PMC9626294 DOI: 10.7507/1002-1892.202203097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To review the research progress regarding the over-the-top technique for anterior cruciate ligament (ACL) reconstruction. METHODS The relevant literature on ACL reconstruction using the over-the-top technique was analyzed for its evolution, clinical application, advantages, and limitations. RESULTS Over-the-top technique for ACL reconstruction is a combined intra- and extra-articular technique. Because it avoids drilling the femoral tunnel, its advantages are mainly highlighted in the protection of the femur. Therefore, it is widely used in children and adolescents with epiphyseal occlusion and in patients with revision reconstruction. In addition, significant improvements in postoperative joint stability, functional scores, and return to exercise rates are found in long-term follow-up studies of patients with primary ACL reconstruction and combined anterolateral tenodesis. However, the technique also has some limitations, such as poor stability of knee flexion after operation, high requirement for graft length, and easy impact of graft in the intercondylar fossa. CONCLUSION The current research results show the effectiveness and safety of the over-the-top technique for primary and revision ACL reconstruction, with the advantages of wide application, simple operation, and quick recovery; however, more researches are needed to further optimize the selection of grafts and femoral condyle management problems, and to clarify the long-term effectiveness.
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25
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Cohen D, Yao PF, Uddandam A, de SA D, Arakgi ME. Etiology of Failed Anterior Cruciate Ligament Reconstruction: a Scoping Review. Curr Rev Musculoskelet Med 2022; 15:394-401. [DOI: 10.1007/s12178-022-09776-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 10/17/2022]
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26
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Tibial slope correction combined with second revision ACLR grants good clinical outcomes and prevents graft rupture at 7-15-year follow-up. Knee Surg Sports Traumatol Arthrosc 2022; 30:2336-2341. [PMID: 34842944 DOI: 10.1007/s00167-021-06750-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 09/12/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To update previously published outcomes (at 2-8 years) of second revision anterior cruciate ligament reconstruction (ACLR) combined with tibial deflexion osteotomy (TDO), after an interval of 5 more years (at 7-15 years), and monitor evolution of clinical scores and progression of osteoarthritis. METHODS The initial retrospective consecutive series included nine patients that underwent one-stage second revision ACLR with TDO, all of whom were contacted for second follow-up at minimum 7 years. An independent observer collected IKDC-SKF, the Lysholm score, and assessed radiographs for signs of osteoarthritis. RESULTS Of the nine original patients, seven were assessed at the clinic, one could only be assessed by telephone, and one was lost to follow-up. At final follow-up of 9.9 ± 3.0 years, the eight patients assessed maintained or improved clinical scores, compared to the previous follow-up at 4.0 ± 2.9 years. The mean Lysholm score improved from 73.8 ± 5.8 (65-82) to 84.5 ± 11.9 (59-95), and IKDC improved from 71.6 ± 6.2 (62-79) to 82.9 ± 12.1 (61-98). Of the three patients that had signs of arthritis at the previous follow-up, the stage of osteoarthritis increased in one (from grade 2 to grade 3), remained unchanged in one, and could not be assessed in one. CONCLUSION At 7-15 years following second revision ACLR with TDO, patients maintained or improved clinical scores compared to the previous follow-up at 2-8 years, without retears or reoperations. Although eight of the nine knees had meniscectomies or meniscal sutures, osteoarthritis progressed in only one of the six knees that had signs of arthritis at the previous follow-up. These results confirm that TDO can protect the ACL graft from retear, with minimal progression of osteoarthritis and/or risks of meniscal tears, suggesting that correction of excessive tibial slope should be considered when performing ACLR, whether a revision or primary procedure.
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Gibbs CM, Hughes JD, Winkler PW, Muenzer M, Lesniak BP, Musahl V. Practice Patterns for Revision Anterior Cruciate Ligament Reconstruction in an Integrated Health Care System. Orthop J Sports Med 2022; 10:23259671221106465. [PMID: 35859651 PMCID: PMC9289917 DOI: 10.1177/23259671221106465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 03/31/2022] [Indexed: 11/15/2022] Open
Abstract
Background While surgeons with high caseload volumes deliver higher value care when performing primary anterior cruciate ligament reconstruction (ACLR), the effect of surgeon volume in the revision setting is unknown. Purposes To determine the percentage of revision ACLR procedures that comprise the practice of high-, medium-, and low-volume surgeons and to analyze associated referral and practice patterns. Study Design Cross-sectional study; Level of evidence, 3. Methods We retrospectively investigated all revision ACLR procedures performed between 2015 and 2020 in a single health care system. Surgeons were categorized as low (≤17), medium (18-34), or high (≥35) volume based on the number of annual ACLR procedures performed. Patient characteristics, activity level, referral source, concomitant injuries, graft type, and treatment variables were recorded, and a comparison among surgeon groups was performed. Results Of 4555 ACLR procedures performed during the study period, 171 (4%) were revisions. The percentage of revision ACLR procedures was significantly higher for high-volume (5%) and medium-volume (4%) surgeons compared with low-volume surgeons (2%) (P < .01). Patients undergoing revision ACLR by a high-volume surgeon had a significantly higher baseline activity level (P = .01). Allografts were used significantly more often by low-volume surgeons (70%) compared with medium-volume (35%) and high-volume (25%) surgeons (P < .01). Bone-patellar tendon-bone (BPTB) and quadriceps tendon (QT) autografts were used significantly more often by high-volume (32% BPTB, 39% QT) and medium-volume (38% BPTB, 14% QT) surgeons compared with low-volume surgeons (15% BPTB, 10% QT) (P < .01). High-volume surgeons were more likely to perform revision on patients with cartilage injuries (P = .01), perform staged revision ACLR (P = .01), and choose meniscal repair (54% high vs 22% medium and 36% low volume; P = .03), despite similar rates of concomitant meniscal tears, compared with low- and medium-volume surgeons. Conclusion In this registry study of an integrated health care system, high-volume surgeons were more likely to perform revision ACLR on patients with higher activity and competition levels. Additionally, high-volume surgeons more commonly performed staged revision ACLR, chose meniscus-sparing surgery, and favored the use of autografts compared with low-volume surgeons.
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Affiliation(s)
- Christopher M Gibbs
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Philipp W Winkler
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Maya Muenzer
- 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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28
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Liu Z, Jiang J, Yi Q, Teng Y, Liu X, He J, Zhang K, Wang L, Teng F, Geng B, Xia Y, Wu M. An increased posterior tibial slope is associated with a higher risk of graft failure following ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:2377-2387. [PMID: 35124715 DOI: 10.1007/s00167-022-06888-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/13/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE The posterior tibial slope (PTS) is considered a risk factor for anterior cruciate ligament (ACL) injury. However, the influence of PTS on graft failure following ACL reconstruction remains relatively unknown. Therefore, this systematic review was conducted to investigate whether PTS could be a potential risk factor for graft failure after ACL reconstruction. METHODS PubMed, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure Database, and Wanfang Database were comprehensively searched from inception to March 31, 2021. Observational studies reporting the associations of medial tibial plateau slope (MTPS) or lateral tibial plateau slope (LTPS) with graft failure after ACL reconstruction were evaluated. RESULTS Twenty studies involving 12 case-control studies, 4 retrospective studies and 4 cross-sectional studies including 5326 patients met the final inclusion criteria. The high heterogeneity and the characteristics of nonrandomized controlled trials limited data synthesis. Fifteen of the 20 included studies detected a significant association between increased PTS and ACL graft failure, while 5 studies concluded that increased PTS was not associated with ACL graft failure. Ten studies suggested that MTPS is associated with ACL graft failure, and six studies suggested that LTPS is associated with ACL graft failure. The mean MTPS values for nonfailure group ranged from 3.5° ± 2.5° to 14.4° ± 2.8°. For the graft failure group, MTPS ranged from 4.71° ± 2.41° to 17.2° ± 2.2°. The mean LTPS values for nonfailure group ranged from 2.9° ± 2.1° to 11.9° ± 3.0°. For the graft failure group, LTPS ranged from 5.5° ± 3.0° to 13.3° ± 3.0°. The reported PTS values that caused ACL graft failure was greater than 7.4° to 17°. CONCLUSION Based on the current clinical evidence, increased PTS is associated with a higher risk of ACL graft failure after ACL reconstruction. Despite various methods of measuring PTS have high reliability, there is still vast disagreement in the actual value of PTS. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Zhongcheng Liu
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730000, Gansu, China
| | - Jin Jiang
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730000, Gansu, China
| | - Qiong Yi
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730000, Gansu, China
| | - Yuanjun Teng
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730000, Gansu, China
| | - Xuening Liu
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730000, Gansu, China
| | - Jinwen He
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730000, Gansu, China
| | - Kun Zhang
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730000, Gansu, China
| | - Lifu Wang
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730000, Gansu, China
| | - Fei Teng
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730000, Gansu, China
| | - Bin Geng
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730000, Gansu, China
| | - Yayi Xia
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730000, Gansu, China.
| | - Meng Wu
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730000, Gansu, China.
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Nazzal EM, Zsidai B, Pujol O, Kaarre J, Curley AJ, Musahl V. Considerations of the Posterior Tibial Slope in Anterior Cruciate Ligament Reconstruction: a Scoping Review. Curr Rev Musculoskelet Med 2022; 15:291-299. [PMID: 35653051 DOI: 10.1007/s12178-022-09767-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE OF REVIEW The significance of posterior tibial slope (PTS) in the setting of anterior cruciate ligament (ACL) injury and reconstruction has been increasingly recognized in recent years. The purpose of this article is to review the biomechanical and clinical studies of PTS in conjunction with ACL injuries, providing an evidence-based approach for the evaluation and management of this patient population. RECENT FINDINGS Several biomechanical and clinical studies suggest that PTS > 12° may be considered with increased strain on the native ACL fibers (or reconstructed graft) and greater anterior tibial translation, predisposing patients to a recurrent ACL injury. The increased rates of ACL injury and graft failure seen in those with increased PTS have garnered attention to diagnose and surgically address increased PTS in the revision ACL setting; however, the role of a slope-reducing high tibial osteotomy (HTO) in primary ACL reconstruction (ACL-R) has yet to be defined. Various HTO techniques to decrease PTS during revision ACL-R have demonstrated promising outcomes, though conclusions are limited by the multifactorial nature of revision surgery and concomitant procedures performed. Recent evidence suggests that increased PTS is a risk factor for failure following ACL-R, which may be mitigated by a slope-reducing HTO. Further investigation is needed to elucidate abnormal PTS values and to determine appropriate indications for a slope-reducing HTO in primary ACL-R.
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Affiliation(s)
- Ehab M Nazzal
- UPMC Freddie Fu Sports Medicine Center, 3200 S Water St., Pittsburgh, PA, 15203, USA.
| | - Bálint Zsidai
- UPMC Freddie Fu Sports Medicine Center, 3200 S Water St., Pittsburgh, PA, 15203, USA.,Department of Orthopaedics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Oriol Pujol
- UPMC Freddie Fu Sports Medicine Center, 3200 S Water St., Pittsburgh, PA, 15203, USA.,Orthopedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Janina Kaarre
- UPMC Freddie Fu Sports Medicine Center, 3200 S Water St., Pittsburgh, PA, 15203, USA.,Department of Orthopaedics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Andrew J Curley
- UPMC Freddie Fu Sports Medicine Center, 3200 S Water St., Pittsburgh, PA, 15203, USA
| | - Volker Musahl
- UPMC Freddie Fu Sports Medicine Center, 3200 S Water St., Pittsburgh, PA, 15203, USA
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Dean RS, DePhillipo NN, LaPrade RF. Posterior Tibial Slope in Patients With Torn ACL Reconstruction Grafts Compared With Primary Tear or Native ACL: A Systematic Review and Meta-analysis. Orthop J Sports Med 2022; 10:23259671221079380. [PMID: 35425846 PMCID: PMC9003651 DOI: 10.1177/23259671221079380] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 11/30/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Increased posterior tibial slope (PTS) is a risk factor for anterior cruciate ligament (ACL) rupture and failure of ACL reconstruction (ACLR) grafts. Purpose: The purpose was to conduct a systematic review of literature on PTS measurements and to conduct a meta-analysis of comparable PTS measurements based on a patient’s ACL status. It was hypothesized that patients with torn ACLR grafts would have significantly larger medial and lateral PTS compared with patients with native ACLs or those who underwent primary ACLR. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were studies that reported medial and/or lateral PTS measurements, those that reported PTS measurements based on ACL status (ie, intact ACL, primary ACL tear, failed ipsilateral ACLR, or revision ACLR), and those that reported their specific PTS measurement technique. Average PTS measurements, measurement location (medial or lateral tibial plateau) and technique, imaging modality used, and ACL status were extracted from each study. Data were pooled using DerSimonian and Laird random-effects models, and results were compared using the Altman interaction test. Results: The literature search identified 1705 studies, of which 82 (N = 12,971 patients) were included. There were 4028 patients in the intact ACL group (31%), 7405 in the primary ACLR group (57%), and 1538 in the failed ACLR group (12%). Measurements were obtained from lateral radiographs in 31 studies (38%), from magnetic resonance imaging in 47 studies (57%), and from computed tomography in 4 studies (5%). The failed ACLR group had a significantly larger lateral PTS (9.55°; 95% CI, 8.47°-10.63°) than either the primary ACL tear (7.13°; 95% CI, 6.58°-7.67°) or intact ACL (5.57°; 95% CI, 5.03°-6.11°) groups (P < .001 for both). The failed ACLR group also had a significantly larger medial PTS (9.05°; 95% CI, 7.80°-10.30°) than the primary (6.24°; 95% CI, 5.71°-6.78°) or intact ACL (6.28°; 95% CI, 5.21°-7.35°) groups (P < .001 for both). Conclusion: Both lateral and medial PTS measurements were greater in patients who had failed previous ACLR than those with a primary ACL tear or an intact native ACL. The lateral PTS of patients with primary ACL tears was greater than those with an intact native ACL.
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Affiliation(s)
- Robert S. Dean
- Beaumont Health, Royal Oak, Michigan, USA
- Twin Cities Orthopedics, Edina, Minnesota, USA
| | - Nicholas N. DePhillipo
- Twin Cities Orthopedics, Edina, Minnesota, USA
- Oslo Sports Trauma Research Center, Oslo, Norway
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Ni QK, Song GY, Zhang ZJ, Zheng T, Cao YW, Zhang H. Posterior tibial slope measurements based on the full-length tibial anatomic axis are significantly increased compared to those based on the half-length tibial anatomic axis. Knee Surg Sports Traumatol Arthrosc 2022; 30:1362-1368. [PMID: 33977310 DOI: 10.1007/s00167-021-06605-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 05/03/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE This study aimed to compare the difference in posterior tibial slope (PTS) measurements based on the full-length and half-length tibial anatomic axes of the same group of patients. It was hypothesized that the obtained PTS values would be affected by the length of tibia chosen during the measurements. METHODS Full-length true lateral tibia radiographs were obtained for each patient who underwent anterior cruciate ligament reconstruction (ACLR) in our department. PTS measurements were obtained by measuring the angle between the full-length or half-length tibial anatomic axis and an average of the lateral and medial tibial plateau. The anatomic axis was defined as the center of the tibial diaphysis. The PTS measurements from the full-length and half-length true lateral tibia radiographs were obtained and compared. Additionally, the absolute difference and the relationship between the two PTS measurements were calculated and analyzed. RESULTS A total of 200 ACL-injured patients were included in this study. The average PTS values using the anatomic axis were 15.9 ± 3.7° and 14.1 ± 3.7° on full-length and half-length true lateral tibial radiographs. There was a significant difference between the measurements with the full-length and half-length tibial radiographs (P < 0.01). Additionally, 49.5% (n = 99) of patients had ≥ 2.0° differences between the full-length and half-length anatomic axis PTS measurement techniques; meanwhile, a strong and significant linear relationship (r = 0.95; P < 0.001) was identified between the two PTS measurements. CONCLUSION There were significant differences and linear relationships between PTS measurements that measured the anatomic axis from full-length and half-length true lateral tibia radiographs. Therefore, the obtained PTS values were strongly associated with the length of tibia chosen during the measurements. Surgeons should pay more attention to the measurement techniques and the tibial length when considering the role of PTS in ACL injury and ACLR failure. Knowledge of the association is very important for calculating potential closing wedge proximal tibial osteotomies to correct excessive PTS in the setting of ACLR failures. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Qian-Kun Ni
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - Guan-Yang Song
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - Zhi-Jun Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - Tong Zheng
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - Yan-Wei Cao
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China
| | - Hui Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xi Cheng District, Beijing, China.
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Winkler PW, Godshaw BM, Karlsson J, Getgood AMJ, Musahl V. Posterior tibial slope: the fingerprint of the tibial bone. Knee Surg Sports Traumatol Arthrosc 2021; 29:1687-1689. [PMID: 33903924 DOI: 10.1007/s00167-021-06578-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 01/13/2023]
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
| | - Brian M Godshaw
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA
| | - Jon Karlsson
- Department for Orthopaedics, Sahlgrenska University Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Alan M J Getgood
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - 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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