The Relationship Between Posterior Tibial Slope and Pediatric Tibial Eminence Fractures

Association Between Posterior Tibial Slope and ACL Injury in Pediatric Patients: A Systematic Review and Meta-analysis

BACKGROUND

The posterior tibial slope (PTS) has been proposed to be a radiographic risk factor for anterior cruciate ligament (ACL) injury in adults. However, this has not been well established in pediatric patients.

PURPOSE

This systematic review and meta-analysis was performed to investigate any association between PTS and ACL tears in the pediatric population.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A systematic review was performed to identify studies that examined the relationship between PTS, medial tibial slope (MTS), and lateral tibial slope (LTS) and ACL tears in children and adolescents aged ≤18 years. Full-text observational studies comparing PTS, MTS, and/or LTS values between pediatric (≤18 years of age) patients with and without ACL injury were included in this analysis. Review articles and case series were excluded. The authors calculated the mean difference (MD) via a restricted maximum-likelihood estimator for tau square and a Hartung-Knapp adjustment for random-effects model.

RESULTS

A total of 348 articles were identified in the initial database search, yielding 10 for final inclusion and analysis. There was no statistically significant association between PTS (MD, 1.13°; 95% CI, -0.55° to 2.80°; P = .10), MTS (MD, 0.36°; 95% CI, -0.37° to 1.10°; P = .27), or LTS (MD, 1.41°; 95% CI, -0.20° to 3.02°; P = .075) and risk for ACL injury in this population.

CONCLUSION

The current study found that unlike what has been shown in adult populations, increased PTS may not be a significant risk factor for ACL tears in pediatric and adolescent patents. LTS was the only measured parameter that neared statistical significance, perhaps suggesting a potential role for this measurement in determining ACL risk if further research is done in this population.

The modified suture-bridge technique for treating avulsion fracture of minors tibial eminence of anterior cruciate ligament: a retrospective study

PURPOSE

This study aimed to evaluate the clinical and radiological outcomes of modified suture-bridge technique fixation for anterior cruciate ligament (ACL) tibial avulsion fracture.

METHOD

Minors who underwent arthroscopic reduction and modified suture bridge fixation of ACL tibial avulsion fracture between January 2018 and January 2022 were retrospectively analyzed. Postoperative MRI and X-ray examinations were performed to evaluate the presence of epiphyseal plate injury and fracture healing. Moreover, KT-1000 side-to-side difference, Lachman test, range of motion (ROM), the subjective Knee score of the International Knee Documentation Committee (IKDC), Lysholm Knee score, and Tegner activity grade score were evaluated preoperatively and at the minimum 1-year follow-up visit.

RESULTS

A total of 16 participants met the inclusion criteria. They had a mean age of 12.6 years (range, 9-16 years); mean time to surgery, 6.9 days (range, 2-13 days) and had a minimum of 12 months clinical follow-up (mean, 25.4 months; range, 12-36 months) after surgery. Postoperative radiographs and MRI showed no injury to the epiphyseal plate, optimal reduction immediately after the operation, and bone union within three months in all patients. All of the following showed significant improvements (pre- vs. postoperatively): mean KT-1000 side-to-side difference (8.6 vs. 1.5; p < 0.05), Lachman tests (2 grade 9 and 3 grade 7 vs. 0 grade 12 and 1 grade 4; p < 0.05), IKDC subjective score (48.3 vs. 95.0; p < 0.05), mean Lysholm score (53.9 vs. 92.2; p < 0.05), mean Tegner activity score (3.2 vs. 8.3; p < 0.05) and mean ROM (42.9°vs 133.1°; p < 0.05).

CONCLUSION

Arthroscopic reduction and modified suture bridge fixation for ACL tibial avulsion fracture is a dependable and recommended treatment that can effectively restore the stability and function of the knee and is worthy of clinical promotion.

Evaluation of Tibial Slope on Radiographs in Pediatric Patients With Tibial Spine Fractures: An Age- and Sex-Matched Study

Background

A recent study has reported that the radiographic measurement of posterior tibial slope (PTS) is larger in male pediatric patients with tibial spine fractures (TSF) than in controls. However, they found no difference in PTS between female patients and controls.

Purpose

(1) To identify whether PTS is larger in female pediatric patients with TSF than in female controls and (2) to validate the relationship between PTS and pediatric TSF in male patients.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

After an a priori power analysis, 84 pediatric patients with TSF (50 female patients and 34 male patients) and 84 age- and sex-matched controls were enrolled in this study. Demographic information, including sex, age, and race, was recorded. Skeletal maturity was determined based on the stage of epiphyseal union on knee radiographs. PTS was defined as the angle between a line perpendicular to the longitudinal axis of the tibia and the posterior inclination of the medial tibial plateau on standard knee lateral radiographs.

Results

The mean age when the TSF occurred was 11.2 ± 2.7 years for female patients and 12.9 ± 2.5 years for male patients. There was no significant difference in skeletal maturity between female patients and female controls or between male patients and male controls. The mean PTS was not significantly different between female patients (8.8°± 2.8°) and female controls (8.3°± 3.1°) (P = .366) or between male patients (9.0°± 2.8°) and male controls (9.3°± 2.6°) (P = .675). Those with a PTS >1 SD (2.9°) above the mean (8.8°) had no greater odds (1.0 [95% CI, 0.4-2.5]; P≥ .999) of having a TSF than others.

Conclusion

PTS was not found to be a risk factor for pediatric TSF in female or male patients in this study.

Decreased Posterior Tibial Slope and Its Association With Pediatric Posterior Cruciate Ligament Injury

BACKGROUND

Recent adult studies have demonstrated that decreased posterior tibial slope angle (PTSA) may be a risk factor for posterior cruciate ligament (PCL) injury. However, there is no study investigating this phenomenon in a pediatric population. Understanding risk factors for PCL injuries among a pediatric population is important given the recent rise in athletic competition/specialization and sports-related injuries.

HYPOTHESIS/PURPOSE

The purpose of this study was to compare PTSA between pediatric patients sustaining a primary PCL tear compared with age- and sex-matched controls. It was hypothesized that pediatric patients sustaining a PCL tear would have a decreased PTSA compared with controls, with decreased PTSA being associated with higher odds of PCL injury.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The records of all patients sustaining a PCL injury between 2006 and 2021 at a level 1 pediatric trauma center were reviewed. Patients aged ≤18 years with magnetic resonance imaging-confirmed PCL tear were included. Excluded were patients with concomitant anterior cruciate ligament tears, previous PCL reconstruction, or previous coronal plane realignment. A control cohort, with their ligament shown as intact on magnetic resonance imaging scans, was matched based on age and sex. PTSA was measured on lateral radiographs of the injured knee or tibia. The mean PTSA was compared between cohorts, and odds ratios were calculated based on the normal slope range (7°-10°) described in the literature, an upper range (>10°), and a lower range (<7°). Inter- and intrarater reliability were determined via calculation of an intraclass correlation coefficient.

RESULTS

Of the 98 patients who sustained a PCL injury in this study period, 59 (60%) met inclusion criteria, and 59 healthy knee controls were matched. There were no differences between the cohorts for age (P = .90), sex (P > .99), or body mass index (P = .74). The PCL cohort had a lower mean ± SD PTSA compared with the control group (5.9°± 2.7° vs 7.3°± 4.3°; P = .03). PTSA <7° was associated with a 2.8 (95% CI, 1.3-6.0; P = .01) times risk of PCL tear. Conversely, PTSA >10° was associated with a 0.27 (95% CI, 0.09-0.81; P = .02) times risk of PCL tear. These PTSA measurements demonstrated acceptable intrarater and interrater reliability.

CONCLUSION

PTSA <7° was associated with an increased odds of PCL injury, whereas a slope >10° was associated with a decreased odds of PCL injury in a pediatric population. These findings corroborate similar outcomes in adult studies; however, further studies are needed to elucidate PTSA as a risk factor for PCL injury.

Evaluation of posterior tibial slope relationship with common knee pathologies in pediatric and adolescent age groups in the Turkish population

Anterior cruciate ligament rupture (ACLR), tibial eminence fracture (TEF), and Osgood-Schlatter disease (OSD) have been linked to a steep posterior tibial slope (PTS) in children and adolescents. This study aims to examine and compare these associations. 418 patients aged 8-18, 237 males and 181 females with knee pain between 2010 and 2019 were included and the patients belonged to the Turkish population. They consisted of ACLR (n = 47), TEF (n = 22), OSD (n = 51), and a control group (n = 298). The study and control groups were compared for PTS, sex, and age, with ACLR, TEF, OSD, retrospectively. The ACLR, OSD, and TEF groups had higher PTS values than the control group (P < 0.001). There was no significant difference in ACLR-OSD, ACLR-TEF, and OSD-TEF comparisons (P = 0.22, P = 0.99, and P = 0.99, respectively). PTS increase was linked to ACLR, TEF, and OSD in the multinomial regression analysis, (P < 0.001). Increase in PTS was associated with ACLR, TEF, and OSD for both males and females (independently of other factors; ACLR: P < 0.001, P < 0.001, OR: 1.59, OR: 2.63, TEF: P = 0.001, P < 0.001, OR: 1.98, OR: 1.44; OSD: P = 0.001, P < 0.001, OR: 1.49, OR: 1.28 for males and females respectively). ACLR, TEF, and OSD are associated with increased PTS in the pediatric and adolescent age groups, and there are differences between these pathologies in terms of the amount of PTS increase, age, and sex. Consideration of age and gender in pediatric and adolescent patients with increased PTS may be useful in predicting pathologies associated with increased PTS. Level of evidence: III retrospective comparative study.

Anatomical factors associated with the development of anterior tibial spine fractures based on MRI measurements

BACKGROUND

Numerous studies have investigated anatomic factors for anterior cruciate ligament (ACL) injuries, such as posterior tibial slope (PTS) and notch width index (NWI). However, anterior tibial spine fracture (ATSF) as a specific pattern of ACL injury, a bony avulsion of the ACL from its insertion on the intercondylar spine of the tibia, has rarely been explored for its anatomical risk factors. Identifying anatomic parameters of the knee associated with ATSF is important for understanding injury mechanisms and prevention.

METHODS

Patients who underwent surgery for ATSF between January 2010 and December 2021 were retrospectively reviewed, and 38 patients were included in the study group. Thirty-eight patients who suffered from isolated meniscal tear without other pathologic findings were matched in a 1:1 fashion by age, sex and BMI to the study group. The lateral posterior tibial slope (LPTS), medial posterior tibial slope (MPTS), medial tibial depth, lateral tibial height, lateral femoral condyle ratio (LFCR) and NWI were measured and compared between the ATSF and control groups. Binary logistic regressions identified independent predictors of ATSF. Receiver operator characteristic (ROC) curves were performed to compare the diagnostic performance and determine the cutoff values of associated parameters.

RESULTS

The LPTS, LFCR and MPTS were significantly larger in the knees in the ATSF group than in the control group (P = 0.001, P = 0.012 and P = 0.005, respectively). The NWI was significantly smaller in the knees in the ATSF group than in the control group (P = 0.005). According to the results of logistic regression analysis, the LPTS, LFCR and NWI were independently associated with ATSF. The LPTS was the strongest predictor variable, and the ROC analysis revealed 63.2% sensitivity and 76.3% specificity (area under the curve, 0.731; 95% CI 0.619-0.844) for values above 6.9.

CONCLUSION

The LPTS, LFCR and NWI were found to be associated with the ATSF; in particular, LPTS could provide the most accurate predictive performance. The findings of this study may aid clinicians in identifying people at risk for ATSF and taking individualized preventive measures. However, further investigation regarding the pattern and biomechanical mechanisms of this injury is required.