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Wang D, Fan H, Hu L, Liang X, Huang W, Li K. Increased knee torsional misalignment associated with femoral torsion is related to non-contact anterior cruciate ligament injury: a case-control study. J Orthop Surg Res 2024; 19:124. [PMID: 38321464 PMCID: PMC10845642 DOI: 10.1186/s13018-024-04609-y] [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: 12/26/2023] [Accepted: 01/31/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Altered axial biomechanics of the knee are recognized as a risk factor for non-contact anterior cruciate ligament (ACL) injury. However, the relationship of knee and segmental torsion to non-contact ACL and combined anterolateral ligament (ALL) injury is unclear. This study aims to determine the relationship of knee and segmental torsion to non-contact ACL injury and to explore their relationship with ALL injuries. METHODS We divided 122 patients with arthroscopically confirmed non-contact ACL injuries into an ACL injury group (isolated ACL injury, 63 patients) and an ACL + ALL injury group (ACL combined with ALL injury,59 patients). Additionally, 90 normal patients with similar age, gender and body mass index (BMI) were matched as a control group. The tibial tubercle-trochlear groove (TT-TG) distance, distal femoral torsion (DFT), posterior femoral condylar torsion (PFCT) and proximal tibial torsion (PTT) were measured using magnetic resonance imaging (MRI). We assessed the differences between the groups using an independent samples t test and utilized receiver operating characteristic (ROC) curves to determine the cut-off value for the increased risk of ACL injury. RESULTS In patients with ACL injury, the measurements of the TT-TG (11.8 ± 3.1 mm), DFT (7.7° ± 3.5°) and PFCT (3.6° ± 1.3°) were significantly higher compared to the control group (9.1 ± 2.4 mm, 6.3° ± 2.7° and 2.8° ± 1.3°, respectively; P < 0.05), but the PTT did not differ between the two groups. The TT-TG, DFT and PFCT were not significantly larger in patients combined with ALL injury. ROC curve analysis revealed ACL injury is associated with TT-TG, DFT and PFCT. CONCLUSIONS Knee torsional alignment is associated with ACL injury, predominantly in the distal femur rather than the proximal tibia. However, its correlation with ALL injury remains unclear. These findings may help identify patients at high risk for non-contact ACL injury and inform the development of targeted prevention and treatment strategies.
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Affiliation(s)
- Dehua Wang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuanjiagang Yuzhong District, Chongqing, 400016, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Hengkai Fan
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Gansu, China
| | - Linlin Hu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xi Liang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuanjiagang Yuzhong District, Chongqing, 400016, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Wei Huang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuanjiagang Yuzhong District, Chongqing, 400016, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Ke Li
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuanjiagang Yuzhong District, Chongqing, 400016, China.
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China.
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Maggioni DM, Giorgino R, Messina C, Albano D, Peretti GM, Mangiavini L. Framing Patellar Instability: From Diagnosis to the Treatment of the First Episode. J Pers Med 2023; 13:1225. [PMID: 37623475 PMCID: PMC10456090 DOI: 10.3390/jpm13081225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/27/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023] Open
Abstract
The patellofemoral joint (PFJ) is a complex articulation between the patella and the femur which is involved in the extensor mechanism of the knee. Patellofemoral disorders can be classified into objective patellar instability, potential patellar instability, and patellofemoral pain syndrome. Anatomical factors such as trochlear dysplasia, patella alta, and the tibial tuberosity-trochlear groove (TT-TG) distance contribute to instability. Patellofemoral instability can result in various types of dislocations, and the frequency of dislocation can be categorized as recurrent, habitual, or permanent. Primary patellar dislocation requires diagnostic framing, including physical examination and imaging. Magnetic resonance imaging (MRI) is essential for assessing the extent of damage, such as bone bruises, osteochondral fractures, and medial patellofemoral ligament (MPFL) rupture. Treatment options for primary dislocation include urgent surgery for osteochondral fragments or conservative treatment for cases without lesions. Follow-up after treatment involves imaging screening and assessing principal and secondary factors of instability. Detecting and addressing these factors is crucial for preventing recurrent dislocations and optimizing patient outcomes.
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Affiliation(s)
- Davide Maria Maggioni
- Residency Program in Orthopaedics and Traumatology, University of Milan, 20122 Milan, Italy;
| | - Riccardo Giorgino
- Residency Program in Orthopaedics and Traumatology, University of Milan, 20122 Milan, Italy;
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milan, Italy; (C.M.); (D.A.); (G.M.P.); (L.M.)
| | - Carmelo Messina
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milan, Italy; (C.M.); (D.A.); (G.M.P.); (L.M.)
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20122 Milan, Italy
| | - Domenico Albano
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milan, Italy; (C.M.); (D.A.); (G.M.P.); (L.M.)
- Dipartimento di Scienze Biomediche, Chirurgiche ed Odontoiatriche, Università degli Studi di Milano, Via della Commenda 10, 20122 Milan, Italy
| | - Giuseppe Michele Peretti
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milan, Italy; (C.M.); (D.A.); (G.M.P.); (L.M.)
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20122 Milan, Italy
| | - Laura Mangiavini
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milan, Italy; (C.M.); (D.A.); (G.M.P.); (L.M.)
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20122 Milan, Italy
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Leite CBG, Merkely G, Farina EM, Smith R, Görtz S, Hazzard S, Asnis P, Lattermann C. Effect of Tibiofemoral Rotation Angle on Graft Failure After Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2023; 51:2291-2299. [PMID: 37454271 DOI: 10.1177/03635465231163856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Coronal and sagittal malalignment of the knee are well-recognized risk factors for failure after anterior cruciate ligament (ACL) reconstruction (ACLR). However, the effect of axial malalignment on graft survival after ACLR is yet to be determined. PURPOSE To evaluate whether increased tibiofemoral rotational malalignment, namely, tibiofemoral rotation angle (TFA) and tibial tubercle-trochlear groove (TT-TG) distance, is associated with graft failure after ACLR. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS In this retrospective matched control study of a single center's database, 151 patients who underwent revision ACLR because of graft failure (ACLR failure group, defined as symptomatic patients with anterior knee instability and an ACL graft tear appreciated on magnetic resonance imaging [MRI] and confirmed during arthroscopic surgery) were compared with a matched control group of 151 patients who underwent primary ACLR with no evidence of failure after ≥2-year follow-up (intact ACLR group). Patients were matched by sex, age, and meniscal injury during primary ACLR. Axial malalignment was assessed on preoperative MRI through the TFA and the TT-TG distance. Sagittal alignment was measured through the posterior tibial slope on MRI. The optimal TFA cutoff associated with graft failure was identified by a receiver operating characteristic curve. The Kaplan-Meier curve with log-rank analysis was performed to evaluate the influence of the TFA on ACLR longevity. RESULTS The mean age was 25.7 ± 10.4 years for the ACLR failure group and 25.9 ± 10.0 years for the intact ACLR group. Among all the included patients, 174 (57.6%) were male. In the ACLR failure group, the mean TFA was 5.8°± 4.5° (range, -5° to 16°), while it was 3.0°± 3.3° (range, -3° to 15°) in the intact ACLR group (P < .001). Neither the TT-TG distance nor the posterior tibial slope presented statistical differences between the groups. The receiver operating characteristic curve suggested an optimal TFA cutoff of 4.5° for graft failure (area under the curve = 0.71; P < .001; sensitivity, 68.2%; specificity, 75.5%). Considering this a threshold, patients who had a TFA ≥4.5° had 6.6 times higher odds of graft failure compared with patients with a TFA <4.5° (P < .001). Survival analysis demonstrated a 5-year survival rate of 81% in patients with a TFA <4.5°, while it was 44% in those with a TFA ≥4.5° (P < .001). CONCLUSION An increased TFA was associated with increased odds of ACLR failure when the TFA was ≥4.5°. Measuring the TFA in patients with ACL tears undergoing reconstruction may inform the surgeon about additional factors that may require consideration before ACLR for a successful outcome.
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Affiliation(s)
- Chilan Bou Ghosson Leite
- Center for Cartilage Repair and Sports Medicine, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gergo Merkely
- Center for Cartilage Repair and Sports Medicine, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Evan M Farina
- Center for Cartilage Repair and Sports Medicine, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard Smith
- Center for Cartilage Repair and Sports Medicine, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Simon Görtz
- Center for Cartilage Repair and Sports Medicine, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sean Hazzard
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Asnis
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christian Lattermann
- Center for Cartilage Repair and Sports Medicine, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Chen KJ, Lee EJ, Kliethermes SA, Scerpella TA. Association of Tibial Tubercle-Trochlear Groove Distance With Risk of ACL Graft Failure. Orthop J Sports Med 2023; 11:23259671231180860. [PMID: 37441506 PMCID: PMC10333637 DOI: 10.1177/23259671231180860] [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: 01/28/2023] [Accepted: 03/09/2023] [Indexed: 07/15/2023] Open
Abstract
Background Limited evidence suggests a positive correlation between tibial tubercle-trochlear groove (TT-TG) distance and the risk of native anterior cruciate ligament (ACL) tear. The relationship between TT-TG distance and the risk of ACL graft failure is unknown. Hypothesis TT-TG distance is independently associated with risk of ACL graft failure. Study Design Cohort study; Level of evidence, 3. Methods All patients who underwent ACL revision surgery between 2010 and 2018 at a single institution were identified. A control cohort underwent primary ACL reconstruction (ACLR) between 2006 and 2015, with no evidence of graft failure at 8.1 ± 2.5 years postoperatively. Record review included anthropometrics, graft type, and estimated Tegner activity score at ≥6 months after primary ACLR. Magnetic resonance imaging (MRI) scans after native ACL tear (controls) or graft failure (revision cohort) were assessed for (1) TT-TG distance, (2) proximal tibial slopes, (3) depth of tibial plateau concavity, and (4) tunnel position (revision cohort). Associations between ACL graft failure and MRI measurements, surgical variables, and patient characteristics were evaluated with logistic regression analyses. Sensitivity analyses, excluding patients with tunnel malposition, were performed to confirm multivariable results in patients with "ideal" tunnel placement. Results Participants included 153 patients who underwent revisions and 144 controls. Controls were older than the patients who underwent revision (26.6 ± 8.8 vs 20.6 ± 7.3 years; P < .001). The mean TT-TG distance and lateral posterior tibial slope (PTS) were smaller for the control group than for the revision group (TT-TG: 9.3 ± 3.9 vs 11.2 ± 4.2 mm; P < .001; lateral PTS: 6.2° ± 3.3° vs 7.2° ± 3.6°; P = .01). TT-TG distance, lateral PTS, and age were associated with risk of ACL graft failure by multivariable analysis (OR, 1.15; 95% CI, 1.07-1.23; P < .001; OR, 1.13; 95% CI, 1.04-1.22; P = .004; and OR, 0.90; 95% CI, 0.87-0.94; P < .001, respectively). With sensitivity analyses, TT-TG distance, lateral PTS, and age at index surgery remained significantly and independently associated with ACL graft failure. Conclusion Increased TT-TG distance, increased lateral PTS, and younger age are independently associated with increased odds of ACL graft failure. Patients with these characteristics may require a more comprehensive strategy to reduce the risk of ACL reinjury.
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Affiliation(s)
- Kallie J. Chen
- University Hospitals Cleveland Medical
Center/Case Western Reserve University School of Medicine, Cleveland, Ohio,
USA
| | - Eric J. Lee
- Department of Orthopedics and
Rehabilitation, University of Wisconsin–Madison, Madison, Wisconsin, USA
| | - Stephanie A. Kliethermes
- Department of Orthopedics and
Rehabilitation, University of Wisconsin–Madison, Madison, Wisconsin, USA
- School of Medicine and Public Health,
University of Wisconsin–Madison, Madison, Wisconsin, USA
| | - Tamara A. Scerpella
- Department of Orthopedics and
Rehabilitation, University of Wisconsin–Madison, Madison, Wisconsin, USA
- School of Medicine and Public Health,
University of Wisconsin–Madison, Madison, Wisconsin, USA
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Wang HJ, Song YF, Ma Y, Lin L, Wang J, Wang YJ, Liu Y, Lu W, Wang F, Yu JK. Higher pathologic threshold of increased tibial tuberosity-trochlear groove distance should be considered for taller patients. Knee Surg Sports Traumatol Arthrosc 2022; 30:3760-3766. [PMID: 35579682 DOI: 10.1007/s00167-022-06992-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 04/21/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The aim of this study was to evaluate the correlation between tibial tuberosity-trochlear groove distance (TT-TG) and body height or knee size, and to find height-related pathologic thresholds of increased TT-TG. METHODS One-hundred and fifty-three patients with recurrent patellar instability and 151 controls were included. The TT-TG was measured on axial computed tomography (CT) images. Femora width and tibial width were selected to represent knee size. The correlation of TT-TG and gender, body height, femora width, and tibial width was evaluated. The height-related pathologic threshold of increased TT-TG was produced according to Dejour's method. To combine TT-TG with body height and knee size, three new indexes were introduced, ratio of TT-TG to body height (RTH), ratio of TT-TG to femoral width (RTF), and ratio of TT-TG to tibial width (RTT). The ability to predict patellar instability was assessed by the receiver-operating characteristic (ROC) curve, odds ratios (ORs), sensitivity, and specificity. RESULTS In patients with patellar instability, TT-TG showed significantly correlation with patient height, femoral width, and tibial width respectively (range r = 0.266-0.283). This correlation was not found in the control group. The pathologic threshold of TT-TG was 18 mm in patients < 169 cm (53%), and the mean TT-TG was 21 mm in patients ≥ 169 cm (54%). There was significant difference in RTH, RTF, and RTT between the two groups. RTH, RTF and RTT have similar large area under the curve (AUC) with TT-TG. CONCLUSIONS TT-TG showed significant correlation with body height and knee size, respectively. The pathologic threshold of increased TT-TG was suggested to be 21 mm for patients [Formula: see text] 169 cm and 18 mm for patients [Formula: see text] 169 cm. Body height-related pathologic threshold provided a supplement for indications of tibial tuberosity medialization. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Hai-Jun Wang
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China.,Peking University Institute of Sports Medicine, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Yi-Fan Song
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China.,Peking University Institute of Sports Medicine, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Yong Ma
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China.,Peking University Institute of Sports Medicine, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Lin Lin
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China.,Peking University Institute of Sports Medicine, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Jian Wang
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China.,Peking University Institute of Sports Medicine, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Yong-Jian Wang
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China.,Peking University Institute of Sports Medicine, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Yang Liu
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China.,Peking University Institute of Sports Medicine, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Wei Lu
- Department of Sports Medicine, First Affiliated Hospital, Shenzhen University, Shenzhen, 518000, China
| | - Fei Wang
- Department of Joint Surgery, Hebei Medical University, Third Affiliated Hospital, No.139 Ziqiang Road, Shijiazhuang, 050000, China.
| | - Jia-Kuo Yu
- Sports Medicine Department, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China. .,Peking University Institute of Sports Medicine, No. 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China.
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Seeing Beyond Morphology-Standardized Stress MRI to Assess Human Knee Joint Instability. Diagnostics (Basel) 2021; 11:diagnostics11061035. [PMID: 34199917 PMCID: PMC8226919 DOI: 10.3390/diagnostics11061035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/25/2021] [Accepted: 06/01/2021] [Indexed: 12/28/2022] Open
Abstract
While providing the reference imaging modality for joint pathologies, MRI is focused on morphology and static configurations, thereby not fully exploiting the modality’s diagnostic capabilities. This study aimed to assess the diagnostic value of stress MRI combining imaging and loading in differentiating partial versus complete anterior cruciate ligament (ACL)-injury. Ten human cadaveric knee joint specimens were subjected to serial imaging using a 3.0T MRI scanner and a custom-made pressure-controlled loading device. Emulating the anterior-drawer test, joints were imaged before and after arthroscopic partial and complete ACL transection in the unloaded and loaded configurations using morphologic sequences. Following manual segmentations and registration of anatomic landmarks, two 3D vectors were computed between anatomic landmarks and registered coordinates. Loading-induced changes were quantified as vector lengths, angles, and projections on the x-, y-, and z-axis, related to the intact unloaded configuration, and referenced to manual measurements. Vector lengths and projections significantly increased with loading and increasing ACL injury and indicated multidimensional changes. Manual measurements confirmed gradually increasing anterior tibial translation. Beyond imaging of ligament structure and functionality, stress MRI techniques can quantify joint stability to differentiate partial and complete ACL injury and, possibly, compare surgical procedures and monitor treatment outcomes.
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