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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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Wen D, Bohlen H, Mahanty S, Wang D. Posterior Tibial Slope Measurements of the Medial and Lateral Plateaus Vary Widely Between Magnetic Resonance Imaging and Computed Tomography. Arthroscopy 2024:S0749-8063(24)00614-5. [PMID: 39209079 DOI: 10.1016/j.arthro.2024.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2024] [Revised: 08/04/2024] [Accepted: 08/06/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE To compare posterior tibial slope (PTS) measurements of the medial tibial plateau (MTP) and lateral tibial plateau (LTP) on magnetic resonance imaging (MRI) versus computed tomography (CT) to determine the agreement of measurement between imaging modalities. METHODS Patients aged 15 to 65 years with concurrent MRI and CT imaging were initially included. Knees with significant arthrosis (Kellgren-Lawrence grade >2), proximal tibia fracture, or artifact obscuring visualization were excluded. Two independent raters measured PTS of the MTP and LTP on paired MRI and CT. Inter- and intrarater reliability were assessed using the intraclass correlation coefficient (ICC). Intermethod agreement was assessed using ICC and Bland-Altman analyses. An acceptable Bland-Altman limit of agreement (LOA) was set at ±2°, requiring 95% of measurement differences between imaging modalities to fall between ±2° for an acceptable level of agreement. RESULTS Forty-six knees in 45 patients met final inclusion criteria. Inter-rater reliability was good for MRI (ICC 0.78-0.83) and moderate to good for CT (ICC 0.64-0.80) studies. Intrarater reliability was moderate to excellent (ICC 0.64-0.94). Intermethod agreement between MRI and CT was poor at the MTP (ICC 0.34-0.42) and moderate at the LTP (ICC 0.59-0.70). Bland-Altman analysis demonstrated high variability of PTS measurements between MRI and CT: 0.16° (95% LOA -6.10° to 6.41°) for MTP for Rater 1; 0.22° (95% LOA -5.01° to 5.45°) for LTP for rater 1; -0.95° (95% LOA -7.22° to 5.33°) for MTP for Rater 2; -0.99° (95% LOA -6.48° to 4.85°) for LTP for rater 2, with only 47.83% to 60.87% of measurement differences falling within the predetermined acceptable LOA of ±2°. CONCLUSIONS Although the inter- and intrarater reliability was moderate to excellent, the degree of agreement between PTS measurements on MRI and CT was highly variable at both medial and lateral plateaus. Although some variability may have been due to the study's limitations, PTS measurements at individual plateaus may not be interchangeable between MRI and CT. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Deborah Wen
- Department of Biomedical Engineering, University of California Irvine, Irvine, California, U.S.A.; Department of Orthopaedic Surgery, University of California Irvine Health, Orange, California, U.S.A
| | - Hunter Bohlen
- Department of Orthopaedic Surgery, University of California Irvine Health, Orange, California, U.S.A
| | - Scott Mahanty
- Charlotte Radiology, Charlotte, North Carolina, U.S.A
| | - Dean Wang
- Department of Biomedical Engineering, University of California Irvine, Irvine, California, U.S.A.; Department of Orthopaedic Surgery, University of California Irvine Health, Orange, California, U.S.A..
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Lin KY, Yang CP, Yao SY, Hung YC, Hung SF, Chen YJ, Chiu CH, Ho CS, Chan YS. Correlation of medial tibial slope and lateral tibial slope measured on radiographs and magnetic resonance imaging in patients with anterior cruciate ligament injury. Jt Dis Relat Surg 2024; 35:504-512. [PMID: 39189558 PMCID: PMC11411889 DOI: 10.52312/jdrs.2024.1558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/11/2024] [Indexed: 08/28/2024] Open
Abstract
OBJECTIVES The study aimed to investigate the correlation between medial tibial slope (MTS) and lateral tibial slope (LTS) on magnetic resonance imaging (MRI), MTS measured by different imaging, and the intra- and interobserver reliability of measurements between reviewers with gaps of experience over 10 years. PATIENTS AND METHODS This retrospective study included 97 patients (93 males, 4 females; mean age: 30.8±8.3 years; range, 17 to 49 years) with anterior cruciate ligament (ACL) injuries who subsequently underwent double-bundle ACL reconstruction by a single surgeon between January 2005 and December 2014. The MTS was measured on lateral knee radiographs, and MTS and LTS were measured on MRIs. Three different reviewers, including a postgraduate year doctor, an orthopedic resident, and an attending orthopedic surgeon, performed the measurements. Each reviewer measured the slope of the same image three times. The correlations of MTS on radiographs and MTS/LTS on MRIs were calculated. Intra- and interobserver reliability were evaluated. RESULTS The average MTS and LTS measured on MRI were not significantly different (6.4° and 6.9°, respectively; p=0.268) and exhibited a moderate positive correlation (r=0.544, p<0.001). The average MTS on radiographs was significantly greater than that on MRI (10.5° and 6.4°, respectively; p<0.001) with a low positive correlation (r=0.480, p<0.001). The intraobserver reliability of the postgraduate year doctor, the orthopedic resident, and the attending orthopedic surgeon were moderate to excellent. The interobserver reliability of MTS on radiographs was excellent (intraclass correlation coefficient [ICC]=0.925; p<0.001). The interobserver reliability of MTS on MRI as well as LTS on MRI was good (ICC=0.755 and 820, respectively; all p values <0.001). CONCLUSION Average MTS and LTS measured on MRI in patients with ACL injury exhibited a moderate positive correlation. The average MTS measured on radiographs was significantly greater than that on MRI with a low positive correlation.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Yi-Sheng Chan
- Department of Orthopedic Surgery, Keelung Chang Gung Memorial Hospital, Keelung City, 204201 Taiwan.
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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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Ravi V, Rehman M, Xia S, Chhabra A, Silva FD. Association of tibial slope alterations with anterior cruciate ligament (ACL) injury and mucoid degeneration. Skeletal Radiol 2024:10.1007/s00256-024-04744-x. [PMID: 39017944 DOI: 10.1007/s00256-024-04744-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/26/2024] [Accepted: 06/27/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVE To compare radiographic measurements of lateral tibial slope (LTS), medial TS (MTS), and coronal TS (CTS) in MRI-defined intact, injured, and mucoid-degenerated native ACL knees and determine inter-reader reliability. MATERIALS AND METHODS Patient records from 2 years at tertiary care hospitals were reviewed for individuals aged 18-100 undergoing 3-Tesla knee MRI and radiographs. Two randomly selected cohorts, control, and pathologic ACLs on MRI with 86 patients each, were age, gender, and BMI-matched. A fellowship-trained musculoskeletal radiologist reevaluated curated images, characterizing ACL status. Two trained medical students independently collected clinical data and measured slopes on blinded radiographs. ICC, Cohen's kappa, and case-control matching were performed using SPSS statistical package, with ICC and ANOVA used for comparisons. RESULTS Among 172 patients with 172 MRIs and radiographs, there were 86 controls and 86 ACL lesions. There were 108/172 (62.79%) males and 64/172 (37.21%) females. ICCs were 0.966 for MTS, 0.975 for LTS, and 0.978 for CTS. Mucoid degeneration patients had a higher BMI and were older than control (p < .05) or completely torn (p < .001) ACL patients. There was no difference in TS between normal and pathologic ACLs; however, LTS-MTS differences were larger with partial tears (2.5 ± 4.9) than normal ACLs by 4.5° (± 1.2, p < .001), complete tears by 4.5° (± 1.3, p < .001), and mucoid degeneration by 4.9° (± 1.5, p = .001). CONCLUSION Various TS measurements are reliable. LTS-MTS differences are associated with different ACL lesions compared to normal ACLs.
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Affiliation(s)
- Varun Ravi
- UT Southwestern Medical School, UT Southwestern Medical Center, Dallas, TX, USA
| | - Mahad Rehman
- UT Southwestern Medical School, UT Southwestern Medical Center, Dallas, TX, USA
| | - Shuda Xia
- UT Southwestern Medical School, UT Southwestern Medical Center, Dallas, TX, USA
| | - Avneesh Chhabra
- Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, USA.
- Department of Orthopedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Flavio Duarte Silva
- Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, USA
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Mansour AA, Steward J, Warth RJ, Haidar LA, Aboulafia A, Lowe WR. Variability Between Full-Length Lateral Radiographs and Standard Short Knee Radiographs When Evaluating Posterior Tibial Slope in Revision ACL Patients. Orthop J Sports Med 2024; 12:23259671241241346. [PMID: 38840791 PMCID: PMC11151757 DOI: 10.1177/23259671241241346] [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: 08/22/2023] [Accepted: 09/11/2023] [Indexed: 06/07/2024] Open
Abstract
Background Increased posterior tibial slope (PTS) has been identified as a risk factor for failure after anterior cruciate ligament (ACL) reconstruction. Correction of PTS may improve outcomes after revision ACL reconstruction. There are conflicting reports demonstrating the measurement of the PTS on standard short knee (SSK) radiographs versus full-length lateral (FLL) radiographs including the entire tibia. Purpose/Hypothesis To compare PTS measurements between SSK and FLL radiographs in patients who failed primary ACL reconstruction. It was hypothesized that there would be high variability between the SSK and FLL radiographic measurements. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods The medial and lateral PTS were measured on the SSK and FLL radiographs of 33 patients with failed primary ACL reconstructions. All measurements were performed by 2 trained independent observers (A.A.M., J.S.), and inter- and intraobserver reliability were calculated using the intraclass correlation coefficient (ICC). Measurements recorded by the observer with the higher intraobserver ICC were used for comparison of the PTS on SSK versus FLL radiographs. Results Both the inter- and the intraobserver reliability values of the PTS measurements were excellent. There was a significant difference in mean PTS on the medial plateau as measured on the SSK and FLL radiographs (11.2°± 5.3° vs 12.5°± 4.6°; P = .03), with the FLL radiographs demonstrating higher PTS. There was also a significant difference in the mean PTS on the lateral plateau as measured on SSK versus FLL radiographs (10.7°± 4.3° vs 12.2°± 4°, respectively; P = .01), with the FLL radiographs demonstrating higher PTS. Notably, 66.67% of the absolute measurements for PTS on the medial plateau differed by ≥2°, with variability as high as 8.5°. Conclusion Results indicated that FLL and SSK radiographs are not interchangeable measurements for PTS associated with failed ACL reconstruction. Because FLL radiographs demonstrate less variability than SSK radiographs, we recommend obtaining them to evaluate these complex patients.
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Affiliation(s)
- Alfred A. Mansour
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Joshua Steward
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ryan J. Warth
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Layla A. Haidar
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Alexis Aboulafia
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Walter R. Lowe
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
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Hung YC, Chuang CA, Yao SY, Lin KY, Hung SF, Chen YJ, Chiu CH, Ho CS, Yang CP, Chan YS. Correlation between higher lateral tibial slope and inferior long term subjective outcomes following single bundle anterior cruciate ligament reconstruction. J Orthop Surg Res 2024; 19:315. [PMID: 38807173 PMCID: PMC11131331 DOI: 10.1186/s13018-024-04795-9] [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] [Received: 03/14/2024] [Accepted: 05/14/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND The impact of anatomical factors, such as the lateral tibial slope (LTS), on outcomes following anterior cruciate ligament (ACL) reconstruction is an area of growing interest. This study was led by the observation that patients with a higher LTS may have different recovery trajectories. HYPOTHESIS/PURPOSE The purpose of this study was to investigate the correlation between a higher LTS and long term subjective outcomes following single-bundle ACL reconstruction. STUDY DESIGN This study was designed as a retrospective cohort study. METHODS The study comprised 138 patients who underwent single-bundle ACL reconstruction. The LTS was measured on preoperative radiographs. Patient-reported outcome measures (PROMs) were collected, which included the Lysholm Knee Score, UCLA Activity Score, IKDC Score, and Tegner Activity Score, over a mean follow-up duration of 137 months. RESULTS A significant negative correlation was found between LTS and all measured PROMs (p < 0.001). The established cut-off value of LTS distinguishing between "Good" and "Fair" Lysholm scores was 8.35 degrees. Female patients have statistically significant higher LTS and lower PROMs scores than male. Patients with LTS greater than or equal to 8.35 had significantly lower PROMs, indicative of poorer functional and subjective outcomes. CONCLUSION Our findings suggest that a higher LTS is associated with inferior subjective outcomes following single-bundle ACL reconstruction in long term. The LTS cut-off value of 8.35 degrees could potentially be used as a reference in preoperative planning and patient counseling. CLINICAL RELEVANCE Understanding the relationship between LTS and ACL reconstruction outcomes could inform surgical planning and postoperative management. These findings highlight the need to consider anatomical variances, such as LTS, when assessing patient-specific risks and recovery expectations, contributing to the advancement of personalized care in sports medicine.
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Affiliation(s)
- Yu-Chieh Hung
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
| | - Chieh-An Chuang
- Comprehensive Sports Medicine Center, Taoyuan Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
| | - Shang-Yu Yao
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
| | - Keng-Yi Lin
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
| | - Shih-Feng Hung
- Department of Orthopedic Surgery, Taoyuan Hospital, Ministry of Health and Welfare, Taoyuan City, 333, Taiwan
| | - Yi-Jou Chen
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
| | - Chih-Hao Chiu
- Comprehensive Sports Medicine Center, Taoyuan Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
| | - Chin-Shan Ho
- Graduate Institute of Sports Science, National Taiwan Sport University, Taoyuan City, 333, Taiwan
| | - Cheng-Pang Yang
- Comprehensive Sports Medicine Center, Taoyuan Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan.
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan.
| | - Yi-Sheng Chan
- Department of Orthopedic Surgery, Keelung Chang Gung Memorial Hospital, Keelung City, 204, Taiwan.
- Comprehensive Sports Medicine Center, Taoyuan Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan.
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan.
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Zhang ZZ, Zhang HZ, Jiang C, Yang R, Chen Z, Song B, Li WP. Steep Posterior Tibial Slope and Excessive Anterior Tibial Translation Are Associated With Increased Sagittal Meniscal Extrusion After Posterior Lateral Meniscus Root Repair Combined With Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2024; 6:100881. [PMID: 38328534 PMCID: PMC10847029 DOI: 10.1016/j.asmr.2023.100881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 12/26/2023] [Indexed: 02/09/2024] Open
Abstract
Purpose To (1) evaluate the clinical and radiographic outcomes of patients with primary anterior cruciate ligament reconstruction (ACLR) with type II posterior lateral meniscus root tear (PLMRT) repair and (2) identify whether increased anterior tibial subluxation of the lateral compartment (ATSLC) and steeper posterior tibial slope (PTS) are associated with sagittal lateral meniscal extrusion (LME). Methods Patients who underwent primary anatomic ACLR with concomitant type II PLMRTs using the all-inside side-to-side repair technique between November 2014 and September 2020 were identified. To be included, patients must have had a minimum of 2 years follow-up. All patients, including those with ATSLC and PTS and sagittal and coronal LME, were retrospectively reviewed clinically and radiologically. The patients were divided into 2 subgroups according to the occurrence of sagittal LME. Results Forty patients were included in this study with a mean follow-up of 44 months (range, 24-94 months). In general, the postoperative parameters, including grade of pivot shift, side-to-side difference, ATSLC, Lysholm score, and International Knee Documentation Committee (IKDC) score, were significantly improved compared with the preoperative ones. However, postoperative sagittal LME was detected to be significantly larger than the preoperative one. Minimal clinically important difference (MCID) analysis for postoperative outcomes showed that the rate of patients who achieved MCID thresholds was 100% for Lysholm, 95% for IKDC, 42.50% for coronal LME, 62.50% for sagittal LME, 40% for ATSLC, and 100% for side-to-side difference. Further comparisons, where patients were divided into 2 subgroups according to the occurrence of sagittal LME, showed significant differences in PTS, ATSLC, and coronal LME. Conclusions Clinical outcomes after type II PLMRT repair with primary ACLR were significantly improved, except for LME, at the 2-year postoperative follow-up. After repair of type II PLMRT injuries, the presence of sagittal LME was associated with increased PTS and ATSLC. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Zheng-Zheng Zhang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, P. R. China
| | - Hao-Zhi Zhang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, P. R. China
- Musculoskeletal Research Laboratory, Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Chuan Jiang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, P. R. China
| | - Rui Yang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, P. R. China
| | - Zhong Chen
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, P. R. China
| | - Bin Song
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, P. R. China
| | - Wei-Ping Li
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, P. R. China
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Oronowicz J, Mouton C, Pioger C, Valcarenghi J, Tischer T, Seil R. The posterior cruciate ligament-posterior femoral cortex angle (PCL-PCA) and the lateral collateral ligament (LCL) sign are useful parameters to indicate the progression of knee decompensation over time after an ACL injury. Knee Surg Sports Traumatol Arthrosc 2023; 31:5128-5136. [PMID: 37805550 DOI: 10.1007/s00167-023-07583-w] [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] [Received: 06/21/2023] [Accepted: 09/06/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE The posterior cruciate ligament-posterior cortex angle (angle between the most vertical part of the anterolateral PCL bundle and the posterior diaphyseal cortex of the femur; PCL-PCA) is the most accurate approach to describe the PCL buckling phenomenon observed in anterior cruciate ligament (ACL)-deficient knees. The aim of this study was to determine whether the PCL-PCA is associated with chronicity of the ACL rupture, the meniscal status, preoperative knee laxity or imaging signs such as the lateral collateral ligament (LCL) sign or the posterior tibial slope (PTS) in ACL-injured knees. METHODS Patients with a primary ACL reconstruction (ACLR) after physeal closure were selected retrospectively from a hospital-based ACL registry from 2015 to 2021. Exclusion criteria were: previous ipsilateral/contralateral knee surgery, previous ipsilateral ACL or meniscal tear, ipsilateral PCL and/or collateral ligament injuries or tibial plateau fracture. The ACL deficiency was defined as chronic if time from injury to MRI was > 6 months. The meniscal status was assessed during ACLR, separately for the medial and lateral meniscus, and classified into no tear, minor or major unstable tear. The MRI analyses included the assessment of the PCL-PCA and the LCL sign. PTS was assessed from the lateral plain radiographs of the injured knee. The side-to-side difference in anterior tibial translation (ATT) at 200N was obtained with the GNRB. RESULTS Eighty-two patients (forty-eight males/thirty-four females) were included in this study. The median PCL-PCA was 16.2° (Q1-Q3: 10.6-24.7) and differed between acute (18.4°) and chronic (10.7°) injuries (p < 0.01). The median PCL-PCA was significantly lower (- 4.6°) in patients with a positive LCL sign (p = 0.03) No significant association could be found between PCL-PCA and meniscal status, PTS or preoperative anterior knee laxity (Lachman, pivot shift and ATT in millimetres). CONCLUSION The PCL-PCA was significantly lower in chronic ACL injuries and in patients with a positive LCL sign, indicating a higher buckling phenomenon of the PCL in these patients. These results support the fact that PCL-PCA and the LCL sign may be useful parameters to indicate the progression of knee decompensation over time after an ACL injury, and therefore may constitute a helpful tool to optimise treatment choice and timing of ACL reconstruction if necessary. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jakub Oronowicz
- Clinic for Orthopaedics and Trauma Surgery, Malteser St. Mary's Hospital, Erlangen, Germany
| | - Caroline Mouton
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg
- Sports Medicine and Science, Luxembourg Institute of Research in Orthopaedics, Luxembourg, Luxembourg
| | - Charles Pioger
- Department of Orthopaedic Surgery, Ambroise Paré Hospital, Paris Saclay University, Paris, France
| | - Jérôme Valcarenghi
- Department of Orthopaedic Surgery, Centre Hospitalier Universitaire Ambroise Paré, Mons, Belgium
| | - Thomas Tischer
- Clinic for Orthopaedics and Trauma Surgery, Malteser St. Mary's Hospital, Erlangen, Germany
- Department of Orthopaedics, University of Rostock, Rostock, Germany
| | - Romain Seil
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg.
- Sports Medicine and Science, Luxembourg Institute of Research in Orthopaedics, Luxembourg, Luxembourg.
- Human Motion, Orthopaedics, Sports Medicine and Digital Methods, Luxemburg Institute of Health, Luxembourg, Luxembourg.
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10
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Garra S, Li ZI, Triana J, Rao N, Alaia MJ, Strauss EJ, Gonzalez-Lomas G, Jazrawi LM. Posterior Tibial Slope in Patients Undergoing Bilateral Versus Unilateral ACL Reconstruction: MRI and Radiographic Analyses. Am J Sports Med 2023; 51:2275-2284. [PMID: 38073181 DOI: 10.1177/03635465231177086] [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: 12/18/2023]
Abstract
BACKGROUND An increased posterior tibial slope (PTS) is a risk factor for primary anterior cruciate ligament (ACL) tears and graft failure, but the PTS has not been well-defined in those who have experienced bilateral ACL injuries. PURPOSE The primary aim was to compare the PTS, as well as the rate of an elevated PTS (>12° on lateral radiography; >7° on magnetic resonance imaging [MRI]), between patients who have undergone bilateral ACL reconstruction (ACLR) versus unilateral ACLR. A secondary purpose was to examine whether these associations remained consistent on both plain radiography and MRI. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS We retrospectively identified patients who underwent primary ACLR at our institution from the years 2012 to 2020. Patients who underwent nonsimultaneous bilateral ACLR (n = 53) were matched to those who underwent unilateral ACLR (n = 53) by age, sex, and body mass index. Exclusion criteria were rotated lateral radiographs, MRI scans of inadequate quality, and concomitant ligament injuries or fractures. Those who had undergone unilateral ACLR with <5-year follow-up were further excluded. There were 3 blinded readers who measured the PTS on lateral radiographs, while the medial PTS (MPTS) and lateral PTS (LPTS) were measured on MRI scans. Bivariate regression was performed to determine the correlation between radiographic and MRI measurements. RESULTS The PTS on radiography (11.26° vs 10.13°, respectively; P = .044) and the LPTS on MRI (7.32° vs 6.08°, respectively; P = .012) in the bilateral ACLR group were significantly greater than those in the unilateral ACLR group but not the MPTS on MRI (4.55° vs 4.17°, respectively; P = .590). The percentage of patients in the bilateral group with a radiographic PTS >12° was 41.0% compared with 13.2% in the unilateral group (P = .012). The bilateral group had a significantly higher rate of an LPTS >7° compared with the unilateral group (53.8% vs 32.1%, respectively; P = .016) but not for an MPTS >7° (P = .190). On MRI, the LPTS (6.90°± 2.73°) was significantly greater than the MPTS (4.41°± 2.92°) (P < .001). There was a weak correlation between MPTS and radiographic PTS measurements (R = 0.24; P = .021), but LPTS and radiographic PTS measurements were not significantly correlated (R = 0.03; P = .810). CONCLUSION Patients who underwent bilateral ACLR had a significantly greater PTS on radiography and a significantly greater LPTS on MRI compared with those who underwent unilateral ACLR. The rate of a radiographic PTS >12° was 2.4 times greater among patients undergoing bilateral ACLR compared with those undergoing unilateral ACLR. PTS measurements on radiography demonstrated a weak to negligible correlation with PTS measurements on MRI, suggesting that future normative PTS values should be reported specific to the imaging modality.
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Affiliation(s)
- Sharif Garra
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
- Division of Orthopedic Surgery, Tel-Hashomer "Sheba" Medical Center, Sackler School of Medicine, Tel-Aviv University, Ramat Gan, Israel
| | - Zachary I Li
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Jairo Triana
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Naina Rao
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Michael J Alaia
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Eric J Strauss
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Guillem Gonzalez-Lomas
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
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11
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Ye Z, Xu J, Chen J, Qiao Y, Wu C, Xie G, Dong S, Zhao J. Steep lateral tibial slope measured on magnetic resonance imaging is the best radiological predictor of anterior cruciate ligament reconstruction failure. Knee Surg Sports Traumatol Arthrosc 2022; 30:3377-3385. [PMID: 35220454 DOI: 10.1007/s00167-022-06923-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/11/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE To identify the radiological predictive risk factors for anterior cruciate ligament reconstruction (ACLR) failure, compare the diagnostic accuracies of different parameters of conventional radiographs and magnetic resonance imaging (MRI), and determine the cutoff values for patients at higher risk. METHODS Twenty-eight patients who were diagnosed as ACLR failure via MRI or arthroscopic examination were included in the study group. They were matched to 56 patients who underwent primary ACLR with the same surgical technique and without graft failure at the minimum 24-month follow-up by age, sex, and body mass index. On true lateral whole-leg radiographs, the posterior tibial slope (PTS) referenced to the tibial mechanical axis (PTS-mechanical), PTS referenced to the tibial proximal anatomical axis (PTS-anatomical), and anterior tibial translation (ATT) were measured. On the sagittal slices of MRI, the medial tibial slope (MTS), medial tibial plateau (MTP) subluxation (MTPsublx), lateral tibial slope (LTS), and lateral tibial plateau (LTP) subluxation (LTPsublx) were obtained. Receiver operator characteristic (ROC) curves were constructed to compare the diagnostic performance and determine the cutoff values of different radiological parameters. RESULTS The study group demonstrated higher values of PTS-mechanical (10.7° ± 2.9° vs 8.7° ± 1.9°, p = 0.003), PTS-anatomical (13.2° ± 2.8° vs 10.5° ± 2.5°, p < 0.001), ATT (10.7 ± 3.3 mm vs 8.9 ± 2.2 mm, p = 0.014), LTS (9.4° ± 2.1° vs 5.5° ± 2.5°, p < 0.001), and LTPsublx (8.2 ± 2.8 mm vs 6.8 ± 1.9 mm, p = 0.009) as compared with the control group. The area under the ROC curve of LTS was significantly larger than that of PTS-mechanical (p = 0.006) and PTS-anatomical (p = 0.020). Based on the maximum Youden indexes, the cutoff values of PTS-mechanical, PTS-anatomical, and LTS were 10.1° (sensitivity, 64.3%; specificity, 78.6%), 12.0° (sensitivity, 71.4%; specificity, 71.4%), and 7.7° (sensitivity, 85.7%; specificity, 80.4%), respectively. CONCLUSION Due to the morphological asymmetry of the MTP and LTP, steep LTS measured on MRI is the best radiological predictor of ACLR failure. Detailed measurement of the LTS on MRI is recommended to evaluate the risk of ACLR failure prior to the surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Zipeng Ye
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Yi Qiao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Chenliang Wu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Guoming Xie
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
| | - Shikui Dong
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
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12
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Morphological Analysis of the Tibial Slope in 720 Adult Knee Joints. Diagnostics (Basel) 2022; 12:diagnostics12061346. [PMID: 35741156 PMCID: PMC9221785 DOI: 10.3390/diagnostics12061346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/24/2022] [Accepted: 05/26/2022] [Indexed: 12/10/2022] Open
Abstract
Background: The tibial slope (TS) defines the posterior inclination of the tibial plateau (TP). The “individual physiological” TS plays a crucial role in knee-joint stability and should be taken into account in knee-joint surgery. The aim of this study was to analyse the specific morphology of the TS for the medial (med) and lateral (lat) TP in relation to patient characteristics and the measurement method. Methods: In this retrospective study, MRI images of knee joints from 720 patients (mean age: 49.9 years [±17.14]) were analysed. The TS was assessed using two established methods according to Hudek (TSH) and Karimi (TSK) for the med and lat TP and gender/side specificity was analysed. Results: TSH for the med and lat TP showed significantly (p < 0.001) different values compared to TSK (TSKmed: 2.6° (±3.7), TSHmed: 4.8° (±3.5); TSKlat: 3.0° (±4.0), TSHlat: 5.2° (±3.9)). The angles of the lat TP were significantly higher than those of the med TP (TSK: p < 0.001; TSH: p = 0.002). Females showed a higher med and lat TS compared to males (p < 0.001). Conclusions: The measurement method has an influence on the values of the TS in knee-joint MRIs. The TS is significantly different for the med and lat TP regardless of the measurement method. There are gender-specific differences for the TS.
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13
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Sabnis BM. A review of role of osteotomy in knee ligament injuries. J Clin Orthop Trauma 2022; 29:101891. [PMID: 35601508 PMCID: PMC9115312 DOI: 10.1016/j.jcot.2022.101891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/06/2022] [Indexed: 11/18/2022] Open
Abstract
Realignment osteotomies around the knee joint are used primarily for management of arthritis. Traditionally, an unstable knee has been considered a contraindication for osteotomy. But with a better understanding of biomechanics of osteotomies and their effect on ligament instabilities, the beneficial role of osteotomies in managing an unstable knee is becoming clearer. This review looks at recent literature on this subject to help in formulating a management plan especially in failed ligament reconstruction patients.
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He M, Li J. Increased lateral femoral condyle ratio measured by MRI is associated with higher risk of noncontact anterior cruciate ligament injury. BMC Musculoskelet Disord 2022; 23:190. [PMID: 35232401 PMCID: PMC8886831 DOI: 10.1186/s12891-022-05134-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Studies have shown a significant association between the radiographically measured lateral femoral condyle ratio (LFCR) and anterior cruciate ligament (ACL) injury. However, it is unclear whether LFCR measured by magnetic resonance imaging (MRI) is associated with a higher risk of noncontact ACL injury. OBJECTIVE To investigate the effect of LFCR on the risk of noncontact ACL injury by MRI. 2 to investigate the association of LFCR measured by MRI with multiple bone morphological risk factors and evaluate the most sensitive risk predictors of noncontact ACL injury. METHODS A total of 116 patients, including 58 subjects with noncontact ACL injury and 58 age-matched and sex-matched controls with only meniscus injury, were included in this retrospective case-control study. LFCR, lateral tibial slope (LTS), lateral tibial height (LTH), medial tibial slope (MTS), and medial tibial depth (MTD) were measured on MRI. The differences in each index between the two groups were compared, and risk factors were screened by single-factor logistic regression analysis. Indicators with P values < 0.1 were included in the logistic regression equation. The critical values and areas under the curve (AUCs) of independent risk factors were determined by receiver operating characteristic (ROC) curve analysis. Finally, the diagnostic performance of each risk factor was evaluated by the Z-test. RESULTS A total of 116 patients who met the inclusion criteria were included in the final analysis (58 cases in the noncontact ACL injury group and 58 cases in the control group). Patients with noncontact ACL injury had a higher femoral LFCR (0.64 ± 0.03) than patients with isolated meniscus tears. Among all the risk factors for ACL injury, the AUC for LFCR was the largest, at 0.81 (95% CI, 0.73-0.88), and when the critical value was 0.61, the sensitivity and specificity for the diagnosis of ACL injury were 0.79 and 0.67, respectively. When combined with LTH (> 2.35 mm), the diagnostic performance was improved. The AUC was 0.85 (95% CI, 0.78-0.92), the sensitivity was 0.83, and the specificity was 0.76. CONCLUSION This study shows that an increased LFCR is related to an increased risk of noncontact ACL injury as determined by MRI. LFCR and LTH are sensitive risk factors for noncontact ACL injury and may help clinicians identify individuals prone to ACL injury, allowing prevention and intervention measures to be applied.
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Affiliation(s)
- Miao He
- Department of Orthopaedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), No. 1 Jiankang Road, Chongqing, 400010, China.
| | - Jie Li
- Department of Orthopaedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), No. 1 Jiankang Road, Chongqing, 400010, China
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