Editorial Commentary: The Segond Fracture Has Multiple Attachments: Yet Another Demonstration of the Anatomical Complexity of the Anterolateral Complex of the Knee

Clinical Outcomes After Anterior Cruciate Ligament Reconstruction in Patients With a Concomitant Segond Fracture: A Systematic Review

BACKGROUND

The Segond fracture can be observed in patients with an anterior cruciate ligament (ACL) tear. It is unclear whether the Segond fracture affects clinical outcomes after ACL reconstruction.

PURPOSE

To investigate whether the presence of a concomitant Segond fracture affects clinical outcomes after ACL reconstruction and to compare clinical outcomes when a Segond fracture is repaired surgically or left unrepaired.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Three databases (PubMed, Embase, Cochrane Library) were searched in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on July 27, 2020. Relevant studies regarding ACL injury with concomitant Segond fracture treated by primary ACL reconstruction were screened in duplicate. Data regarding patient characteristics and clinical outcomes were extracted. Descriptive data are presented, and a random-effects model was used to pool amenable data.

RESULTS

A total of 5 studies examining 2418 patients (987 female; 40.8%), mean age 25.4 years, were included in this study. There were 304 patients with a Segond fracture (mean age, 28.1 years; 35.9% female) and 2114 patients without a Segond fracture (mean age, 25.1 years; 41.5% female). Four studies directly compared outcomes between patients with an unrepaired Segond fracture and no Segond fracture. One study reported 12 patients who underwent ACL reconstruction and repair of a Segond fracture. Among 4 studies, 11 of 292 (3.8%) graft failures/revision surgeries were reported in the groups that had Segond fracture, whereas 145 of 2114 (6.9%) graft failures/revision surgeries were reported in groups that did not have Segond fracture. No significant difference was observed in the risk of graft failure between the 2 groups, with a pooled risk ratio of 0.59 (95% CI, 0.32-1.07; P = .08; I2 = 0%). No clinically significant differences were observed with regard to International Knee Document Committee score, Lysholm score, Tegner activity scale, and postoperative knee laxity between the group with Segond fracture and those without.

CONCLUSION

An unrepaired Segond fracture does not appear to have any significant negative effect on postoperative stability or risk of graft failure or revision surgery after ACL reconstruction. Future prospective studies may be warranted to confirm the finding that patients with combined ACL injury and Segond fracture may have outcomes comparable with those of ACL-injured patients without a Segond fracture when isolated ACL reconstruction is performed.

Editorial Commentary: Lateral Extra-Articular Tenodesis Results in Better Stability After Anterior Cruciate Ligament Reconstruction for Patients With High-Grade Pivot Shifts

Magnetic resonance imaging of the torn anterior lateral ligament (ALL) is inconsistent and subject to significant intra- and interobserver variability. Like that of an anterior cruciate ligament (ACL), an ALL tear can vary in degree (first, second, or third) and location (tibial or femoral side). These variations may impact the appropriate surgical intervention. Relevant biomechanical data indicate that the deep iliotibial band fibers are more important than the ALL in controlling pivot shift. Lateral compartment overconstraint after ALL reconstruction does not appear to be a biomechanical or clinical issue. An ALL reconstruction creates a nonisometric construct (tight in extension and lax in flexion), allowing physiologic internal tibial rotation at 90° flexion, whereas lateral extra-articular tenodesis (LET) is more isometric, limiting physiologic internal tibial rotation at 90° flexion. The indications for a combined ACL/ALL reconstruction are evolving, but a Segond fracture and ligamentous hyperlaxity of ≥5 using the modified Beighton system seem reasonable. An ACL/LET reconstruction results in better stability for patients with high-grade pivot shifts.