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Kayaalp ME, Winkler P, Zsidai B, Lucidi GA, Runer A, Lott A, Hughes JD, Musahl V. Slope Osteotomies in the Setting of Anterior Cruciate Ligament Deficiency. J Bone Joint Surg Am 2024; 106:1615-1628. [PMID: 39066689 DOI: 10.2106/jbjs.23.01352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
➤ Posterior tibial slope (PTS) of ≥12° represents an important risk factor for both anterior cruciate ligament (ACL) injury and ACL reconstruction failure.➤ PTS measurements can significantly differ on the basis of the imaging modality and the measurement technique used. PTS should be measured on strictly lateral radiographs, with a recommended proximal tibial length of 15 cm in the image. The PTS measurement can be made by placing 2 circles to define the proximal tibial axis, 1 just below the tibial tubercle and another 10 cm below it. PTS measurements are underestimated when made on magnetic resonance imaging and computed tomography.➤ Slope-reducing osteotomies can be performed using a (1) supratuberosity, (2) tubercle-reflecting transtuberosity, or (3) infratuberosity method. The correction target remains a topic of debate. Although it is controversial, some authors recommend overcorrecting the tibial slope slightly to a range of 4° to 6°. For instance, if the initial slope is 12°, a correction of 6° to 8° should be performed, given the target tibial slope of 4° to 6°.➤ Clinical outcomes following slope-reducing osteotomies have been favorable. However, potential complications, limited data with regard to the impact of slope-reducing osteotomies on osteoarthritis, and uncertainty with regard to the effects on the patellofemoral joint are notable concerns.➤ Patients with complex deformities may need biplanar osteotomies to comprehensively address the condition.
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Affiliation(s)
- Mahmut Enes Kayaalp
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Orthopaedics and Traumatology, Istanbul Kartal Training and Research Hospital, Istanbul, Turkey
| | - Philipp Winkler
- Department for Orthopaedics and Traumatology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
| | - Balint Zsidai
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
| | - Gian Andrea Lucidi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Armin Runer
- Department of Sports Orthopaedics, Klinikum rechts der Isar Haus, Technical University of Munich, Munich, Germany
| | - Ariana Lott
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania
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Kayaalp ME, Apseloff NA, Lott A, Kaarre J, Hughes JD, Ollivier M, Musahl V. Around-the-knee osteotomies part 1: definitions, rationale and planning-state of the art. J ISAKOS 2024; 9:645-657. [PMID: 38460600 DOI: 10.1016/j.jisako.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/11/2024]
Abstract
Knee osteotomies are essential orthopedic procedures with the ability to preserve the joint and correct ligament instabilities. Literature supports the correlation between lower limb malalignment and outcomes after knee ligament reconstruction and cartilage procedures. Concepts such as joint line obliquity, posterior tibial slope angle, and intra-articular deformity correction are integral components of both preoperative planning and postoperative evaluations. The concept of preserving and/or restoring joint line congruence during simultaneous correction of varus or valgus deformity can be achieved through several different approaches. With advancements in osteotomy research and surgical planning technology, the surgical decision-making has increased in complexity. Based upon a patient's specific deformity, decisions need to be made whether to perform a single-level (proximal tibia or distal femur) versus double-level (both proximal tibia and distal femur) osteotomy, and whether to correct deformity in a single plane (coronal or sagittal) or perform a biplanar osteotomy, correcting two of the malalignments in either coronal, sagittal, or axial planes. Osteotomy procedures prioritize safety, reproducibility, precision, and meticulous planning. Equally important is the proactive management of possible complications and the implementation of preventive strategies for complications such as hinge fractures and unintentional changes to alignment in other planes. This review navigates the intricate landscape of lower limb alignment, commencing with foundational definitions and rationale for performing osteotomies, progressing through the planning phase, and addressing the critical aspect of complication prevention, all while looking ahead to anticipate future advancements in this field. However, rotational osteotomies and tibial tubercle osteotomies in isolation or as an adjunct procedure are beyond the scope of this review.
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Affiliation(s)
- M Enes Kayaalp
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA; Department Orthopaedics and Traumatology, Istanbul Kartal Training and Research Hospital, Istanbul, 34865, Turkiye
| | - Nicholas A Apseloff
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA
| | - Ariana Lott
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA
| | - Janina Kaarre
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, 41345, Sweden; Sahlgrenska Sports Medicine Center, Gothenburg, 41345, Sweden
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA
| | - Matthieu Ollivier
- Aix Marseille Univ, CNRS, ISM, Inst Movement Sci, Marseille, 13009, France
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, 15203, USA.
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Lott A, James MG, Kaarre J, Höger S, Kayaalp ME, Ollivier M, Getgood A, Hughes JD, Musahl V. Around-the-knee osteotomies part II: Surgical indications, techniques and outcomes - State of the art. J ISAKOS 2024; 9:658-671. [PMID: 38604568 DOI: 10.1016/j.jisako.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/24/2024] [Accepted: 04/01/2024] [Indexed: 04/13/2024]
Abstract
Recent advances in surgical techniques and planning for knee-based osteotomies have led to improvements in addressing lower extremity malalignment. Part 1 of this review presented the biomechanical and clinical rationale of osteotomies, emphasizing the importance of osteotomies for restoring normal knee kinematics. In Part 2 of this review, indications, surgical technique and outcomes of osteotomies to correct coronal, sagittal and axial plane deformities will be examined. Traditional high tibial and distal femoral osteotomies will be discussed in addition to more recent advanced techniques including biplanar corrections and double-level osteotomies, as well as slope-correcting osteotomies. Patient-specific instrumentation and its use in more complex corrections will also be addressed.
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Affiliation(s)
- Ariana Lott
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael G James
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Janina Kaarre
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Center, University of Pittsburgh, Pittsburgh, PA, USA; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
| | - Svenja Höger
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Center, University of Pittsburgh, Pittsburgh, PA, USA; Department of Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - M Enes Kayaalp
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Center, University of Pittsburgh, Pittsburgh, PA, USA; Department of Orthopaedics and Traumatology, Istanbul Kartal Training and Research Hospital, Istanbul, Turkey
| | | | - Al Getgood
- Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Center, University of Pittsburgh, Pittsburgh, PA, USA.
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Liu X, Yang H, Jun Z, Li L, Wang Z, Li Z, Liu J. Outcomes of physeal-sparing posterior cruciate ligament reconstruction for adolescents with an open physis. INTERNATIONAL ORTHOPAEDICS 2024; 48:1525-1532. [PMID: 37989809 DOI: 10.1007/s00264-023-06037-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/07/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE The posterior cruciate ligament (PCL) rupture rarely occurs, especially in skeletally immature adolescents, and poses a dilemma in appropriately managing the open physis with its vast growth potential. However, although many epiphyseal-protecting techniques for anterior cruciate ligament (ACL) reconstruction have been reported, a similar problem in PCL reconstruction has received scant attention and needs more relevant research. So, this study aims to evaluate the short-term clinical and imaging results of the arthroscopic physeal-sparing reconstruction program. METHOD All the 13 patients we reviewed in this study have accepted the arthroscopic physeal-sparing PCL reconstruction from January 2019 to December 2022 in our Department of Orthopedics. Primary demographic data collected include gender (8 males and 5 females), age (11-15 years, average 13.3 years), follow-up period (15-35 months, average 25.2 months), injury mechanism (nine non-contact injuries and four contact injuries), and days following injury (1-10 days, average 5.3 days). The assessment of clinical outcomes included pre- and postoperative physical examination, knee functional scores, and imaging data. RESULT All patients in this study were followed up with an average 25.2-month (range 15-35 months) follow-up period. All the cases preoperatively had a positive posterior drawer test and turned negative at the final follow-up. The average ROM improved from 103.6° ± 11.4° to 132.6° ± 3.6° at the last follow-up (p < 0.05). The VAS score decreased from 5.8 ± 1.6 to 0.9 ± 0.5 (p < 0.05); the average KT-1000 healthy-side to affected-side difference decreased from 11.3 ± 1.6 to1.8 ± 0.5 mm. The comparison of all the knee functional scores (IKDC, Tegner scores, and Lysholm) at preoperative and last follow-up showed a significant difference (p < 0.05). None of the cases had operation-related complications, and all recovered to sports well. CONCLUSION The arthroscopic physeal-sparing posterior cruciate ligament reconstruction is a dependable and recommended treatment for posterior cruciate ligament rupture in adolescents with open physis, showing a striking improvement in knee function without growth arrest and angular deformity of the affected limb in the short-term follow-up.
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Affiliation(s)
- Xu Liu
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, Sichuan, 646000, People's Republic of China
| | - Haibo Yang
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, Sichuan, 646000, People's Republic of China
| | - Zhong Jun
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, Sichuan, 646000, People's Republic of China
| | - Lingzhi Li
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, Sichuan, 646000, People's Republic of China
| | - Zhaojun Wang
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, Sichuan, 646000, People's Republic of China
| | - Zhong Li
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, Sichuan, 646000, People's Republic of China.
| | - Juncai Liu
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, Sichuan, 646000, People's Republic of China.
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Vieider RP, Mehl J, Rab P, Brunner M, Schulz P, Rupp MC, Siebenlist S, Hinz M. Malrotated lateral knee radiographs do not allow for a proper assessment of medial or lateral posterior tibial slope. Knee Surg Sports Traumatol Arthrosc 2024; 32:1462-1469. [PMID: 38629758 DOI: 10.1002/ksa.12170] [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: 11/03/2023] [Revised: 03/13/2024] [Accepted: 03/20/2024] [Indexed: 05/31/2024]
Abstract
PURPOSE The aim of this study was to investigate whether malrotation of lateral knee radiographs influences posterior tibial slope (PTS) measurements. METHODS Lateral knee radiographs of all patients who underwent knee surgery at a single institution between June 2022 and January 2023 and received multiple lateral knee radiographs were included. Radiographs were categorised as malrotated lateral knee radiographs or lateral knee radiographs based on the radiographic distance between the medial and lateral posterior femoral condyles. Medial PTS (MPTS) and lateral PTS (LPTS) were evaluated on malrotated lateral knee radiographs and lateral knee radiographs and compared using the paired t test. Intra- and interrater reliability between four raters were assessed for MPTS and LPTS measurements. RESULTS A total of 92 lateral knee radiographs (46 pairs of malrotated lateral knee radiographs and lateral knee radiographs; 50.0% right side) from 46 patients (33.2 ± 12.4 years, 69.6% male) were included. Mean posterior femoral condyle distance in malrotated lateral knee radiographs was 8.1 ± 4.4 mm. Overall, MPTS and LPTS were significantly higher on malrotated lateral knee radiographs versus lateral knee radiographs (medial: 10.5 ± 3.2° vs. 9.7 ± 3.5°, p < 0.05; lateral: 10.6 ± 3.4° vs. 9.7 ± 3.3°, p < 0.05). Mean absolute difference between MPTS and LPTS on malrotated lateral knee radiographs versus lateral knee radiographs were |1.9| ± |1.5|° and |2.0| ± |1.8|°, respectively. Intrarater reliability was 'moderate' and interrater reliability was 'good' for both MPTS and LPTS. CONCLUSION Malrotation of lateral knee radiographs led to a significant distortion of both the MPTS and LPTS. In clinical practice, attention should be placed on the (mal)rotation of lateral knee radiographs, especially in patients for whom a slope-correcting osteotomy is being discussed. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Romed P Vieider
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Julian Mehl
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Peter Rab
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Moritz Brunner
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Phillip Schulz
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | | | - Sebastian Siebenlist
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Maximilian Hinz
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
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Nedaie S, Vivekanantha P, O'Hara K, Slawaska-Eng D, Cohen D, Abouali J, Hoshino Y, Nagai K, Johnson J, de Sa D. Decreased posterior tibial slope is a risk factor for primary posterior cruciate ligament rupture and posterior cruciate ligament reconstruction failure: A systematic review. Knee Surg Sports Traumatol Arthrosc 2024; 32:167-180. [PMID: 38226729 DOI: 10.1002/ksa.12025] [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: 09/19/2023] [Revised: 11/11/2023] [Accepted: 12/01/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE To determine bony knee morphological factors associated with primary posterior cruciate ligament (PCL) rupture or PCL graft failure after PCL reconstruction. METHODS Three databases, namely MEDLINE, PubMed and EMBASE, were searched on 30th May 2023. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data such as receiver operating characteristic curve parameters, as well as p-values for comparisons of values between patients with PCL pathology and control patients, were recorded. RESULTS Nine studies comprising 1054 patients were included. Four studies reported that patients with PCL injury had flatter medial posterior tibial slopes (MTS) than controls, with mean values of 4.3 (range: 3.0-7.0) and 6.5 (range: 5.0-9.2) degrees, respectively. Two studies reported an MTS cutoff value ranging below 3.90-3.93° being a significant risk factor for primary PCL rupture or PCL graft failure. Two studies reported that shallow medial tibial depths were associated with primary PCL rupture, with mean values of 2.1 (range: 2.0-2.2) and 2.6 (range: 2.4-2.7) mm in PCL injury and control groups, respectively. Stenotic intercondylar notches and femoral condylar width were not consistently associated with PCL injuries. CONCLUSION Decreased MTS is associated with primary PCL rupture and graft failure after PCL reconstruction with values below 3.93° being considered as a significant risk factor. Less common risk factors include shallow medial tibial depth, while femoral condylar width and parameters with regards to the intercondylar notch, such as notch width, notch width index and intercondylar notch volume, demonstrated conflicting associations with primary or secondary PCL injuries. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Soroush Nedaie
- Michael DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Kaylin O'Hara
- Michael DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - David Slawaska-Eng
- McMaster University Medical Center, Division of Orthopaedic Surgery, Hamilton, Ontario, Canada
| | - Dan Cohen
- McMaster University Medical Center, Division of Orthopaedic Surgery, Hamilton, Ontario, Canada
| | - Jihad Abouali
- Department of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Jansen Johnson
- McMaster University Medical Center, Division of Orthopaedic Surgery, Hamilton, Ontario, Canada
| | - Darren de Sa
- McMaster University Medical Center, Division of Orthopaedic Surgery, Hamilton, Ontario, Canada
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