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

Patients With Segond Fracture Demonstrate Similar Rates of Return to Sport and Psychological Readiness After Anterior Cruciate Ligament Reconstruction: A Matched Cohort Study at Minimum 2-Year Follow-Up

PURPOSE

To compare clinical outcomes, rate of return to sports, and psychological readiness among patients undergoing anterior cruciate ligament reconstruction (ACLR) with and without concomitant Segond fracture.

METHODS

We retrospectively identified patients who underwent primary ACLR from January 2012 to December 2020 with minimum 2-year follow-up. Exclusion criteria were additional ligamentous injury, age <16 years, or a concomitant lateral augmentation procedure. Preoperative knee radiographs were reviewed to identify Segond fractures. Identified patients were matched 1:2 to controls by age/sex/body mass index/graft type. Charts were reviewed for pre- and postoperative knee stability. Surveys administered included preinjury sport participation and return status, Lysholm score, Tegner activity scale, and ACL-Return to Sport Index (ACL-RSI), a metric of psychological sport readiness. Multivariable logistic regression was conducted to identify predictors of return to sport.

RESULTS

There were 120 patients who were included in the final analysis (40 Segond, 80 controls) at a mean follow-up of 5.7 ± 2.4 years. A total of 52.5% of patients received bone-patellar tendon-bone autograft. The overall rate of return to sport was 79.5% in the Segond group compared with an 83.8% rate of return in the control group (P = .569). In total, 48.7% of the Segond group and 56.8% of the control group returned to their preinjury level of sport (P = .415). Lysholm (89.6 ± 10.3 vs 85.4 ± 16.7, P = .296), Tegner (5.7 ± 1.8 vs 6.1 ± 2.2, P = .723), and ACL-RSI (62.2 ± 25.4 vs 56.6 ± 25.4, P = .578) scores were similar between Segond and control groups. There was a single graft failure in the Segond group 5 years' postoperatively. Increasing ACL-RSI score was significantly predictive of return to sport (P < .001).

CONCLUSIONS

Patients who had an ACL tear and a concomitant Segond fracture who underwent isolated ACLR without lateral augmentation procedures had similar clinical outcomes and rates of return sport compared with a matched isolated ACLR control group at minimum 2-year follow-up. There was no significant difference in psychological readiness between groups as measured by the ACL-RSI.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Impacts of Segond Fractures on Anterior Cruciate Ligament Reconstruction Outcomes

INTRODUCTION

Segond fractures, characterized by avulsion injuries at the lateral tibial condyle's anterolateral structure (ALS) attachment, often coincide with anterior cruciate ligament (ACL) injuries, potentially leading to knee instability. However, the influence of Segond fractures on knee stability after ACL reconstruction remains uncertain. Despite documented ALS reconstructions, there is a lack of consensus regarding the assessment of ALS failure and the criteria for surgical interventions. This study aimed to determine if Segond fracture presence impacts ACL reconstruction outcomes, utilizing patient-reported subjective assessments and healthcare providers' objective evaluations.

MATERIALS AND METHODS

This retrospective study encompassed 639 patients (328 males, 311 females; mean age 26.9 years) who underwent ACL reconstruction, with a follow-up of at least one year. Subjects were divided into two groups: Segond fractures diagnosed through radiographic findings (Group S+, n = 17) and no Segond fractures (Group S-, n = 622). Clinical evaluation included the 36-item Short Form Survey (SF-36), Lysholm score, visual analog scale (VAS) for knee pain, knee injury and osteoarthritis outcome score (KOOS), and knee instability assessment via Telos SE (Telos Japan, Tokyo, Japan). Statistical comparisons were performed between the two groups.

RESULTS

At the final follow-up, all SF-36 subscales improved in all eight subscales compared to before surgery, reaching national standard scores; no significant inter-group differences were evident. Lysholm scores were 93.0 ± 12.1 (Group S+) and 91.7 ± 10.9 (Group S-) (P = 0.62), VAS for knee pain was 10.0 ± 18.0 (Group S+) and 11.9 ± 16.9 (Group S-) (P = 0.62), total KOOS was 89.0 ± 17.4 (Group S+) and 90.7 ± 9.9 (Group S-) (P = 0.39), and anterior tibial translation differences were 2.8 ± 3.0 mm (Group S+) and 2.7 ± 2.9 mm (Group S-) (P = 0.73). All these values represent postoperative measurements. No significant discrepancies existed between groups across evaluation methods.

CONCLUSIONS

This study's results suggest that Segond fractures have minimal impact on clinical ACL reconstruction outcomes, as assessed through both patient-reported subjective evaluations and objective healthcare provider evaluations. Segond fractures' significance in postoperative outcomes questions the necessity of ALS reconstruction.

Lateral meniscal injury without medial meniscal injury indicates the existence of the Segond fracture in ACL-deficient knees

Background/Objective

The purpose of this study was to find factors indicating the occurrence of the Segond fracture, a specific type of anterolateral ligament injury.

Methods

From January 2015 to December 2017, we retrospectively reviewed the medical records of patients diagnosed with acute anterior cruciate ligament (ACL) injury who underwent reconstruction within 90 days of injury. Diagnosis of the Segond fracture was determined either by magnetic resonance imaging or plain radiographs. Factors examined were: age at surgery, sex, body mass index (kg/m2), status of menisci, and activities led to ACL injury. After univariate screening, multivariate logistic regression analyses were performed. Patients were divided into four groups based on the presence of lateral meniscal (LM) and/or medial meniscal (MM) injuries and compared with respect to the occurrence of Segond fractures.

Results

A total of 375 patients were included (163 males, 212 females), with mean age 25.8 years old. Among them, 22 of 375 (5.9 %) had a Segond fracture. We identified injured lateral menisci (adjusted odds ratio (aOR), 3.029; 95 % Confidence Interval (CI), 1.206-7.609; P = 0.018), intact medial menisci (aOR, 0.229; 95 % CI, 0.065-0.810; P = 0.022), and higher body mass index (aOR, 1.102; 95 % CI, 1.008-1.205; P = 0.034) as factors indicative of the occurrence of Segond fracture. LM injury without MM injury suggested the existence of a Segond fracture.

Conclusion

LM injury without a MM injury indicated the occurrence of a Segond fracture. Higher body mass index also increased the risk for Segond fracture occurrence.

Untreated Injuries to the Anterolateral Capsular Structures Do Not Affect Outcomes and Kinematics after Anatomic Anterior Cruciate Ligament Reconstruction

BACKGROUND

Injuries to the anterolateral complex (ALC) may contribute to increased rotatory knee laxity. However, it has not been evaluated whether such injuries affect in vivo kinematics when treated in situ. The purpose of this study was to determine the grade of ALC injury and its effect on kinematic and clinical outcomes of ACL-injured patients 24 months after anatomic ACL reconstruction. It was hypothesized that injury to the ALC would be significantly related to patient-reported outcomes (PROs) and in vivo knee kinematics during downhill running.

METHODS

Thirty-five subjects (mean age: 22.8 ± 8.5 years) participating in a randomized clinical trial to compare single- and double-bundle ACL reconstruction were included in the study. Subjects were divided into two groups based on the presence or absence of injury to the ALC, as determined on MRI scans performed within 6 weeks of injury. None of the patients underwent treatment for these ALC injuries. At 24 months, PROs, including the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Knee injury and Osteoarthritis Outcome Score (KOOS) and in vivo knee kinematics during downhill running, were obtained. Pivot-shift test results, PROs and in vivo knee kinematics were compared between groups with and without ALC injury using the Pearson's Chi Squared test and Mann-Whitney U test with significance set at p < 0.05.

RESULTS

The average interval between injury and performing the MRI scans was 9.5 ± 10 days. ALC injury was observed in 17 (49%) study participants. No significant differences were detected in PROs and in vivo kinematics between subjects with and without ALC injury (n.s.).

CONCLUSION

The findings of this study demonstrate that MRI evidence of an ALC injury does not significantly affect in vivo knee kinematics and PROs even in individuals with a high-grade ALC injury. Injuries to the ALC as observed on MRI might not be a useful indication for an anterolateral procedure.

Anterior cruciate ligament rupture and associated Segond fracture: Incidence and effect on associated ligamentous and meniscal injuries

Introduction

The Segond fracture is an avulsion fracture of the lateral tibial plateau and is widely considered to be pathognomonic of anterior cruciate ligament (ACL) rupture. In addition to ACL rupture, Segond fractures have also been noted to be associated with significant intra-articular pathology such as meniscal injuries as well as extra-articular pathology such as collateral ligament injuries. This is likely due to the fact that the presence of a Segond fracture may represent increased rotatory instability. Whilst several studies have demonstrated the association of a Segond fracture with significant intra-articular pathology, there is a paucity of literature assessing if the combination of an ACL rupture and Segond fracture gives rise to higher rates of concomitant ligamentous and meniscal injuries. The primary objective of this study is to determine if patients with ACL ruptures associated with Segond fractures have higher rates of concomitant ligamentous and meniscal injury, when compared to patients with ACL ruptures without a Segond fracture.

Methods

A retrospective review of all patients who underwent ACL reconstruction in a single institution between 2014 to 2018 was conducted. A review of the patients’ demographics, operative notes, and radiographs was performed. X-rays and MRI scans were double-read by a board-certified radiologist and Orthopaedic surgeon.

Results

A total of 414 subjects were included. The incidence of Segond fracture was 2.4%. The mean age was 24.7±7.4 (range 16 to 60) years and 26.7±7.6 (range 16 to 38) years in patients with and without Segond fractures respectively. 89.9% of patients suffered a non-contact mechanism of injury, with sports injuries being most common (79.5%). There was a significantly higher rate of isolated lateral meniscus tears in patients with Segond fractures compared to those without (50% v.s. 20.8%) based on pre-operative MRI. (p<0.05) There were no other significant differences in associated ligamentous injuries.

Conclusion

The incidence of Segond fracture associated with ACL rupture is 2.4%. There is a significantly higher risk of a concomitant isolated lateral meniscus tear in ACL ruptures associated with a Segond fracture. There is no significantly higher risk of concomitant ligamentous injuries in ACL ruptures associated with a Segond fracture.

Current trends in the anterior cruciate ligament part 1: biology and biomechanics

A trend within the orthopedic community is rejection of the belief that "one size fits all." Freddie Fu, among others, strived to individualize the treatment of anterior cruciate ligament (ACL) injuries based on the patient's anatomy. Further, during the last two decades, greater emphasis has been placed on improving the outcomes of ACL reconstruction (ACL-R). Accordingly, anatomic tunnel placement is paramount in preventing graft impingement and restoring knee kinematics. Additionally, identification and management of concomitant knee injuries help to re-establish knee kinematics and prevent lower outcomes and registry studies continue to determine which graft yields the best outcomes. The utilization of registry studies has provided several large-scale epidemiologic studies that have bolstered outcomes data, such as avoiding allografts in pediatric populations and incorporating extra-articular stabilizing procedures in younger athletes to prevent re-rupture. In describing the anatomic and biomechanical understanding of the ACL and the resulting improvements in terms of surgical reconstruction, the purpose of this article is to illustrate how basic science advancements have directly led to improvements in clinical outcomes for ACL-injured patients.Level of evidenceV.