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Murakami R, Taketomi S, Yamagami R, Kono K, Kawaguchi K, Kage T, Arakawa T, Kobayashi T, Tanaka S. Initial graft tension affects patellofemoral alignment during anatomical anterior cruciate ligament reconstruction. Knee 2024; 49:108-115. [PMID: 38880041 DOI: 10.1016/j.knee.2024.05.011] [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: 03/25/2024] [Revised: 05/17/2024] [Accepted: 05/28/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND This study aimed to evaluate the effects of the differences in initial graft tension (IGT) on patellofemoral alignment in the axial plane after anatomical anterior cruciate ligament reconstruction (ACLR). METHODS A total of 102 patients who underwent primary anatomical ACLR using a bone-patellar-tendon-bone autograft were enrolled. The grafts were fixed with maximum manual force at full knee extension (higher graft tension; H group) and with 5-20 N at 20° knee flexion which corresponded to 80 N at full knee extension (lower graft tension; L group) pulls in 39 and 63 patients, respectively. All patients underwent computed tomography of the bilateral knee joints with knee extension 1 week postoperatively. The patellofemoral alignment (sulcus angle, lateral trochlear inclination angle, lateral patellofemoral angle (LPFA), condylar-patellar angle (CPA) (lateral facet, patellar tilt), congruence angle, and bisect offset index) on the axial computed tomography images were evaluated, and the side-to-side differences (SSDs) between the injured knee and the contralateral knee were calculated. RESULTS Congruence angle SSD was remarkably higher in the H group than in the L group (3.8 ± 4.7 vs. 0.4 ± 5.7, P < 0.01). Furthermore, the LPFA SSD and CPA (patellar tilt) SSD were significantly higher in the H group (-1.8 ± 3.1 vs. -0.4 ± 2.7, P = 0.04 and -1.6 ± 2.8 vs. -0.3 ± 2.7, P = 0.04, respectively). CONCLUSIONS A higher IGT during anatomical ACLR induces a lateral shift and tilt of the patella against the femur immediately after surgery compared with the lower IGT.
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Affiliation(s)
- Ryo Murakami
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuji Taketomi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Ryota Yamagami
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kenichi Kono
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kohei Kawaguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomofumi Kage
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takahiro Arakawa
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takashi Kobayashi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Severyns M, Mallet J, Santoni B, Barnavon T, Germaneau A, Vendeuvre T, Drame M. Radiographic measurement of the congruence angle according to Merchant: validity, reproducibility, and limits. Knee Surg Relat Res 2023; 35:1. [PMID: 36627648 PMCID: PMC9830856 DOI: 10.1186/s43019-023-00175-5] [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: 07/11/2022] [Accepted: 12/31/2022] [Indexed: 01/12/2023] Open
Abstract
PURPOSE The objective of this study was to analyze the intra- and interobserver variability of this measurement according to a strict methodology and on a representative sample of the general population, as well as to identify the possible difficulties of measurement in case of patellar or trochlear dysplasia. METHODS This observational study involved radiographic analysis by three independent observers of a total of 50 patients who had a loaded patellofemoral X-ray taken with the knee flexed to 45°. An initial reading was taken to measure the angle of the trochlear sulcus, the Merchant angle, and to classify the knees according to a possible trochlear dysplasia and/or patellar dysplasia according to Wiberg. A second measurement was then performed to analyze intraobserver agreement. Interobserver agreement was measured on all radiographic measurements (n = 100). RESULTS The Merchant patellofemoral congruence angle showed good intraobserver concordance ranging from 0.925 (95% CI 0.868-0.957) to 0.942 (95% CI 0.898-0.967), as well as interobserver concordance ranging from 0.795 (95% CI 0.695-0.862) to 0.914 (95% CI 0.872-0.942). Poor results were found in terms of interobserver concordance on the measurement of the Merchant angle in case of stage 3 Wiberg patella ranging from 0.282 (95% CI -0.920 to 0.731) to 0.611 (95% CI 0.226-0.892). CONCLUSION Congruence angle is one of most commonly used measurements for patellar tracking. However, the convexity of the patellar surface makes it difficult to identify the patellar apex on its intraarticular facet, making the measurement of the Merchant congruence angle unreliable and not very reproducible in cases of stage 3 Wiberg patella. Registration N°IRB 2021/139.
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Affiliation(s)
- M. Severyns
- Department of Orthopaedic Surgery, Clinique Porte Océane, 85340 Les Sables d‘Olonne, France ,grid.11166.310000 0001 2160 6368Pprime Institut UP 3346, CNRS, University of Poitiers, 86000 Poitiers, France ,Hôpital Pierre Zobda Quitman, 97261 Fort-de-France Cedex, France
| | - J. Mallet
- Department of Orthopaedic Surgery, Clinique Porte Océane, 85340 Les Sables d‘Olonne, France
| | - B. Santoni
- Department of Orthopaedic Surgery, Clinique Porte Océane, 85340 Les Sables d‘Olonne, France
| | - T. Barnavon
- Department of Orthopaedic Surgery, Clinique Porte Océane, 85340 Les Sables d‘Olonne, France
| | - A. Germaneau
- grid.11166.310000 0001 2160 6368Pprime Institut UP 3346, CNRS, University of Poitiers, 86000 Poitiers, France
| | - T. Vendeuvre
- grid.11166.310000 0001 2160 6368Pprime Institut UP 3346, CNRS, University of Poitiers, 86000 Poitiers, France
| | - M. Drame
- grid.412874.c0000 0004 0641 4482Department of Clinical Research and Innovation, University Hospital of Martinique, 97200 Fort-de-France, France
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Chen J, Ye Z, Wu C, Zhang X, Zhao J, Xie G. Sulcus depth, congruence angle, Wiberg index, TT-TG distance, and CDI are strong predictors of recurrent patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2022:10.1007/s00167-022-07245-3. [PMID: 36463567 DOI: 10.1007/s00167-022-07245-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 11/21/2022] [Indexed: 12/07/2022]
Abstract
PURPOSE To characterize patellofemoral morphology, determine radiological cutoff values based on computed tomography (CT) images, and clarify predominant anatomic risk factors in young patients with recurrent patellar dislocation (RPD). METHODS A total of 212 knees (age 23.0 ± 5.3 years, female: male = 110:102) with CT-confirmed RPD were enrolled for analysis. The control group was matched by age and sex (2:1). Patellofemoral and trochlear morphology, patellofemoral alignment, and other parameters were assessed by CT. Standardized methods were used for measurements. Receiver operating characteristic (ROC) curves and the areas under the ROC curve (AUCs) were used to assess accuracy in diagnosing RPD. The index of union (IU) was employed to identify a cutoff value for risk. A binary logistic regression model (Forward, LR) was constructed, and standardized coefficients were calculated to compare the relative strength of different predictors. Factors included in the model were employed to calculate distributions in the studied population. RESULTS The majority of measurements showed a significant difference between the RPD and control groups when comparing mean values. The AUC value was favorable for sulcus depth and significantly better than that for other trochlear morphology parameters (P < 0.0001). Cutoff values were 0.58 for the Wiberg index, 153.3° for the sulcus angle, 3.6 mm for the sulcus depth, 1.94 for the trochlear width ratio, 16.2° for the lateral trochlear inclination, 17.2° for the patellar lateral tilt, 25.5° for the congruence angle, 1.2 for the patellar height [Caton-Deschamps index (CDI)], 6.1° for the knee rotation, and 16.4 mm for the tibial tubercle-trochlear groove (TT-TG) distance. A binary logistic regression model (χ2 = 20.826, P = 0.008) including the Wiberg index, sulcus depth, congruence angle, patellar height (CDI), and TT-TG distance was constructed for RPD (P ≤ 0.015), which showed excellent diagnostic performance, as indicated by an AUC of 0.989 (95% CI, 0.979 to 0.998). Sulcus depth showed the strongest relationship with RPD, followed by the congruence angle and Wiberg index, as indicated by the standardized coefficients - 1.43, 1.02, and 0.97, respectively. Eighty-seven percent of the RPD population had sulcus depth ≤ 3.6 mm. CONCLUSIONS This study provides a systematic reference of cutoff values based on CT data. The combination of five anatomic risk factors (sulcus depth, congruence angle, Wiberg index, TT-TG distance, and CDI) may be an excellent predictor of RPD as initial risk assessment. Sulcus depth, as the most frequently observed anatomic risk factor, showed the best diagnostic performance among trochlear morphological parameters and the strongest relationship with RPD, followed by the congruence angle and Wiberg index. In clinical practice, the sulcus depth, congruence angle, Wiberg index, TT-TG distance, and CDI with the proposed cutoff values can be used in combination to evaluate RPD. When assessing trochlear morphology, sulcus depth is recommended as the best radiological parameter. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jiebo Chen
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Zipeng Ye
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Chenliang Wu
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Xueying Zhang
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China.
| | - Guoming Xie
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China.
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Reconstruction of the medial patellofemoral ligament with nonresorbable suture tape normalizes patellar maltracking independent of patella-side fixation technique. Knee Surg Sports Traumatol Arthrosc 2022:10.1007/s00167-022-07256-0. [PMID: 36454291 DOI: 10.1007/s00167-022-07256-0] [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: 07/29/2022] [Accepted: 11/23/2022] [Indexed: 12/04/2022]
Abstract
PURPOSE Patellar maltracking caused by a rupture of the medial patellofemoral ligament (MPFL) can be improved by MPFL reconstruction (MPFL-R) with a tendon graft. Nonresorbable suture tape (FiberTape®, FT) is possibly becoming an option to tendon grafts for MPFL-R. Patella-side fixation of FT can be performed with suture anchors or via soft-tissue fixation. The aim of this study was to investigate patellar tracking considering soft-tissue-based and anchor-based patella-side fixation techniques. METHODS In eight fresh-frozen human knee joint specimens (m/f 4/4; age 75 ± 10 years), the MPFL was identified, and a rupture was placed near the femoral insertion site. In the study group (SG; 4 knees), soft-tissue fixation of the FT was performed at the medial patellar retinaculum; in the control group (CG; 4 knees), FT was fixed at the patella via suture anchors. For native MPFL (nMPFL), ruptured ("injured") MPFL (iMPFL) and reconstructed MPFL (FT-MPFL-SG, respectively, FT-MPFL-CG) cone beam CT scans were performed in 15°, 30°, and 45° of knee joint flexion. Patellar tracking was assessed using the radiological parameters patellar tilt (PT), congruence angle (CA) and posterior patellar edge-trochlear groove ratio (PTR). RESULTS All recorded radiological parameters increased, respectively, decreased in the CG and SG from the nMPFL to the iMPFL state. After MPFL-R, all parameters normalized when compared to the intact state (nMPFL), regardless of patella-side fixation technique. All investigated parameters of patellotrochlear alignment were positively, respectively, negatively significantly (p < 0.05) correlated throughout all evaluated conditions (nMPFL, iMPFL, FT-MPFL-SG, FT-MPFL-CG). CONCLUSION MPFL-R with a nonresorbable suture tape can normalize patellar maltracking in fresh-frozen human knee joint specimens in earlier degrees of knee joint flexion independent of patella-side fixation technique. The investigated parameters of patellotrochlear alignment correlate with each other.
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Chen J, Ye Z, Wu C, Zhang X, Zhao J, Xie G. Patellar shift ratio (PSR) is the optimal measurement for characterising lateral patellar shift and a reliable predictor of recurrent patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2022:10.1007/s00167-022-07240-8. [PMID: 36427078 DOI: 10.1007/s00167-022-07240-8] [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: 06/27/2022] [Accepted: 11/15/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE To propose a new measurement, the patellar shift ratio (PSR), for characterising lateral patellar shift; to determine its diagnostic accuracy in predicting recurrent patellar dislocation (RPD); and to identify the effect of patellar tilt and morphology on shift measurements. METHODS Variables including the PSR, bisect offset (BSO), BSO adjusted by trigonometric analysis, linear patellar displacement (LPD) distance and congruence angle were measured on axial computed tomography (CT). Furthermore, PSR was classified into grades determined by the threshold generated by receiver operating characteristic (ROC) curves. Youden's index was used to identify the ideal threshold on the curve. The area under the ROC curve (AUC) values and likelihood ratios were calculated to assess diagnostic performance in predicting RPD. Correlation analysis was conducted to identify the effects of lateral tilt and the Wiberg index on lateral shift. Intra- and interobserver reliability were evaluated using the intraclass correlation coefficient. RESULTS The study included 54 RPD patients and 54 controls matched by sex and age. The threshold for PSR was 24.3% (sensitivity, 96.30%; specificity, 85.19%). AUCs were categorised as excellent for all protocols (P < 0.001). The positive likelihood ratio of the PSR for predicting RPD was 6.50. PSR was categorised in terms of lateral trochlear quadrants consisting of 25% increments. Lateral patellar tilt showed a strong positive correlation with BSO (P < 0.001); moderate correlations with PSR, LPD distance and adjusted BSO (P ≤ 0.001); and a weak correlation with congruence angle (P = 0.034). The Wiberg index presented a positive moderate correlation with BSO (P < 0.001), while no correlation was found with PSR, LPD distance, or congruence angle (n.s.). All parameters showed good repeatability (intraobserver) and reproducibility (interobserver). CONCLUSIONS The PSR showed excellent diagnostic performance as indicated by likelihood ratios, measurement accuracy (being relatively resistant to the effects of tilt and the Wiberg index), and intra- and interobserver reliability. The optimal PSR threshold for predicting RPD risk was 24.3%, and the grade of PSR (normal, 1-4) was also a reliable and easily calculated predictor of RPD. This quantifying method to characterise lateral patellar shift is an alternative useful method for clinical assessments of RPD patients and for research on patellofemoral congruence. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jiebo Chen
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Zipeng Ye
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Chenliang Wu
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Xueying Zhang
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China.
| | - Guoming Xie
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China.
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