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Mayer P, Leiprecht J, Schlumberger M, Geßlein M, Immendörfer M, Richter J, Schuster P. Malrotation Strongly Influences Posterior Tibial Slope Measurement on Lateral Radiographs of the Knee. Orthop J Sports Med 2025; 13:23259671251330309. [PMID: 40376391 PMCID: PMC12078948 DOI: 10.1177/23259671251330309] [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: 10/18/2024] [Accepted: 11/22/2024] [Indexed: 05/18/2025] Open
Abstract
Background Posterior tibial slope (PTS) is commonly measured on lateral radiographs, but there is an ongoing discussion on which criteria are essential as quality standards. Purpose/Hypothesis The purpose of this study was to evaluate the effect of malrotation of the tibia on lateral radiographs for PTS measurement. It was hypothesized that malrotation alters the measured PTS. Study Design Descriptive laboratory study. Methods An infratuberositary osteotomy was performed on a tibial saw bone model, and 3 conditions-2 with increased PTS-were tested with the same experimental setup (series 1, closed osteotomy; series 2, 5-mm anterior opening; series 3, 10-mm anterior opening). Long lateral radiographs were taken from +12.5° of external tibial rotation (ETR) to -20° of internal tibial rotation (ITR), in steps of 2.5°. PTS was measured with the mechanical axis (MA) and the proximal anatomic axis (PAA). In addition, the distance between the medial and lateral posterior tibial condyles was measured (in mm). Results In test series 1, between +12.5° to 0° of ETR and 0° to-20° of ITR, a change in PTS of 2.8°± 1.0 (ETR) and 3.7°±1.3 (ITR) for the MA and 3.7°± 1.4 (ETR) and 4.1°±1.5 (ITR) for the PAA was detected. In test series 2, changes of 1.5°± 0.5 (ETR) and 3.7±1.3 (ITR) for the MA and 1.6°± 0.6 (ETR) and 4.3°±1.4 (ITR) for the PAA were observed; likewise, in test series 3, changes of 1.8°± 0.7 (ETR) and 3.7°±1.3 (ITR) for the MA and 2.2°± 0.9 (ETR) and 4.2°±1.3 (ITR) for the PAA were observed. ETR of +12.5° resulted in a distance of 5 mm, and ITR of -20° resulted in a distance of 10 mm between the posterior tibial condyles in all testing conditions. There was no significant difference among the 3 testing conditions (P > .05). A change of 1 mm in distance was equivalent to 2° (ITR) or 2.5° (ETR) of change in rotational alignment and 0.4° of change in PTS measurement, irrespective of whether MA or PAA was used. Conclusion Tibial malrotation strongly influences PTS measurement on lateral radiographs. ETR leads to an underestimation, and ITR to an overestimation, of PTS. Every 1° of change in rotational alignment was equivalent to 0.2° of change in PTS measurement. For a reliable PTS measurement on lateral radiographs, the posterior tibial condyles should be superimposed exactly. Clinical Relevance Dependent on PTS values, surgical correction of the PTS can be indicated. For a correct indication, it is of utmost importance to be able to determine the posterior slope exactly. This investigation demonstrates the effect of tibial rotation on PTS measurement and defines quality criteria, as well as a simple grading system for lateral radiographs for the measurement of the PTS. This helps surgeons to interpret radiographs correctly, allowing a better decision-making process, if and when a corrective osteotomy for PTS correction is indicated.
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Affiliation(s)
- Philipp Mayer
- Centre for Sports Orthopaedics and Special Joint Surgery, Orthopaedic Hospital Markgroeningen, Markgroeningen, Germany
- Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft), Schwarzenbek, Germany
| | - Janina Leiprecht
- Centre for Sports Orthopaedics and Special Joint Surgery, Orthopaedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Michael Schlumberger
- Centre for Sports Orthopaedics and Special Joint Surgery, Orthopaedic Hospital Markgroeningen, Markgroeningen, Germany
- Sports Clinic, Trauma and Orthopaedic Surgery, Stuttgart Hospital, Stuttgart, Germany
| | - Markus Geßlein
- Department of Orthopaedics and Traumatology, Paracelsus Medical University, Clinic Nuremberg, Nuremberg, Germany
| | - Micha Immendörfer
- Centre for Sports Orthopaedics and Special Joint Surgery, Orthopaedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Jörg Richter
- Centre for Sports Orthopaedics and Special Joint Surgery, Orthopaedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Philipp Schuster
- Centre for Sports Orthopaedics and Special Joint Surgery, Orthopaedic Hospital Markgroeningen, Markgroeningen, Germany
- Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft), Schwarzenbek, Germany
- Department of Orthopaedics and Traumatology, Paracelsus Medical University, Clinic Nuremberg, Nuremberg, Germany
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Shin CH, Syed AN, Swanson ME, Lawrence JTR, Baghdadi S, Cruz AI, Ellis HB, Fabricant PD, Green DW, Kerrigan A, Kirby J, Kocher M, Kushare IV, Jay Lee R, MacDonald JP, McKay SD, Parikh SN, Patel NM, Yen YM, Schmale GA, Shea KG, Mistovich RJ, Ganley TJ. Morphological Risk Factors for Pediatric Anterior Cruciate Ligament Tears and Tibial Spine Fractures. Am J Sports Med 2025:3635465251334120. [PMID: 40292911 DOI: 10.1177/03635465251334120] [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] [Indexed: 04/30/2025]
Abstract
BACKGROUND Both tibial spine fractures (TSFs) and anterior cruciate ligament (ACL) tears result in functional loss of knee stability. Nonetheless, it remains unclear why some patients sustain ACL tears, whereas others have TSFs. PURPOSE To identify the common morphological risk factors for pediatric ACL tears and TSFs and to determine the morphological differences between them using multiplanar reconstruction of magnetic resonance imaging (MRI). STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Age- and sex-matched participants (159 total [53 ACL tears, 53 TSFs, and 53 controls]) aged <18 years who visited a pediatric tertiary-care center for ACL tears, TSFs, or anterior knee pain from March 2009 to April 2023 were included. Each group comprised 41 male and 12 female participants. Data on demographic characteristics and estimated bone age based on the knee MRI atlas were retrospectively collected, and various knee morphological parameters were evaluated using multiplanar reconstruction of MRI. Parameters showing significant differences among the 3 groups were selected as independent variables for multivariable multinomial logistic regression analysis, with the groups as dependent variables. RESULTS The mean chronological age at the time of MRI was 13.2 ± 2.3 years. Height, weight, body mass index, bone age, articular medial tibial slope, and bony medial tibial slope did not differ among the groups. Articular lateral tibial slope was independently associated with the occurrence of both ACL tears (relative risk ratio [RRR], 1.42 [95% confidence interval (CI), 1.16-1.74]; P = .001) and TSFs (RRR, 1.33 [95% CI, 1.10-1.62]; P = .004). A high notch width index was a protective factor against ACL tears (RRR, 0.86 [95% CI, 0.77-0.96]; P = .006) but not against TSFs (RRR, 1.01 [95% CI, 0.91-1.12]; P = .848). CONCLUSION A high articular lateral tibial slope was a common risk factor for ACL tears and TSFs. Patients with ACL tears had a narrower intercondylar notch than those with TSFs and controls.
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Affiliation(s)
- Chang Ho Shin
- Seoul National University Children's Hospital, Seoul, Republic of Korea
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Akbar N Syed
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Morgan E Swanson
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - J Todd R Lawrence
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Soroush Baghdadi
- University of California, Los Angeles, Los Angeles, California, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Aristides I Cruz
- Hasbro Children's Hospital, Providence, Rhode Island, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Henry B Ellis
- Scottish Rite for Children, Dallas, Texas, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Peter D Fabricant
- Hospital for Special Surgery, New York, New York, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Daniel W Green
- Hospital for Special Surgery, New York, New York, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alicia Kerrigan
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julia Kirby
- Austin Health, Heidelberg, Victoria, Australia
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mininder Kocher
- Boston Children's Hospital, Boston, Massachusetts, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Indranil V Kushare
- Texas Children's Hospital, Houston, Texas, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - R Jay Lee
- Johns Hopkins Hospital, Baltimore, Maryland, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James P MacDonald
- Nationwide Children's Hospital, Columbus, Ohio, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Scott D McKay
- Texas Children's Hospital, Houston, Texas, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shital N Parikh
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Neeraj M Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yi-Meng Yen
- Boston Children's Hospital, Boston, Massachusetts, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Gregory A Schmale
- Seattle Children's Hospital, Seattle, Washington, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kevin G Shea
- Lucile Packard Children's Hospital, Palo Alto, California, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - R Justin Mistovich
- Case Western Reserve University, Cleveland, Ohio, USA
- University Hospitals Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Theodore J Ganley
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Voskuilen R, Dietvorst M, van der Steen M, Janssen RPA. A small notch width index, steeper medial and lateral tibial slope and higher lateral/medial tibial slope ratio are relevant knee morphological factors for ACL injuries in skeletally immature patients-A systematic review. J Exp Orthop 2025; 12:e70211. [PMID: 40123680 PMCID: PMC11928882 DOI: 10.1002/jeo2.70211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2024] [Revised: 02/03/2025] [Accepted: 02/05/2025] [Indexed: 03/25/2025] Open
Abstract
Purpose The incidence of anterior cruciate ligament (ACL) injuries in skeletally immature patients has drastically increased over the last decades. Morphology of the knee might play an important role. This literature review provides a systematic overview of knee morphological factors relevant to ACL injury in skeletally immature patients. The hypothesis of the present study is that multiple knee morphological parameters-such as a steep medial and lateral tibial slope (MTS and LTS) and a narrow intercondylar notch-can be identified as potentially relevant factors for ACL injury in this population. Methods Systematic review according to PRISMA guidelines. MEDLINE, Embase and Cochrane were searched in December 2023 for studies reporting on knee morphology and ACL injury in skeletally immatures. The following inclusion criteria were used: English/Dutch studies, full-text available, human studies and skeletally immature patients. Parameters with clinical homogeneity and presented in two or more studies as means with standard deviation were included in a meta-analysis using RevMan. Parameters that could not be included in the meta-analyses were presented in a descriptive manner. Results After screening 1825 studies, a total of 18 studies were included, of which 16 studies had parameters included in the meta-analyses. These studies investigated 31 knee morphological factors for ACL injury in skeletally immatures. Meta-analyses identified a smaller notch width index (NWI) (0.25 vs. 0.26, mean difference: -0.02 95% confidence interval [CI]: -0.03 to -0.01, p ≤ 0.00001) steeper MTS and LTS (4.8° vs. 3.6° (mean difference: 0.55° 95% CI: 0.09-1.01, p = 0.02) and 4.3° vs 2.8° (mean difference: 2.04° 95% CI: 0.75-3.32, p = 0.0003), respectively) and higher LTS/MTS ratio as risk factors for ACL injury in skeletally immature patients. Conclusions A small NWI, steeper MTS and LTS and higher LTS/MTS ratios were identified as relevant knee morphological factors for ACL injuries in skeletally immature patients. Level of Evidence Level III.
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Affiliation(s)
- Robin Voskuilen
- Department of Orthopaedic Surgery & TraumaMáxima Medical CenterEindhoventhe Netherlands
| | - Martijn Dietvorst
- Department of Orthopaedic Surgery & TraumaMáxima Medical CenterEindhoventhe Netherlands
| | - Marieke van der Steen
- Department of Orthopaedic Surgery & TraumaMáxima Medical CenterEindhoventhe Netherlands
- Department of Orthopaedic Surgery & TraumaCatharina Hospital EindhovenEindhoventhe Netherlands
| | - Rob P. A. Janssen
- Department of Orthopaedic Surgery & TraumaMáxima Medical CenterEindhoventhe Netherlands
- Orthopaedic Biomechanics, Department of Biomedical EngineeringEindhoven University of TechnologyEindhoventhe Netherlands
- Chair Value‑Based Health Care, Department of Paramedical SciencesFontys University of Applied SciencesEindhoventhe Netherlands
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Calek AK, Hochreiter B, Ek SJ, Carr A, Young D, Baré J, Lording TD. Medial meniscal and bony slopes are higher in knees with failed ACL reconstruction than in patients with successful ACL reconstruction. Knee 2024; 50:59-68. [PMID: 39126926 DOI: 10.1016/j.knee.2024.07.022] [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: 01/30/2024] [Revised: 07/19/2024] [Accepted: 07/21/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND We aimed to compare tibial soft tissue and bony slopes in patients with failed and non-failed ACL reconstructions (ACLR). We hypothesized that patients with failed ACLR have increased slopes compared to non-failed ACLR, and unexplained failures have higher slopes than failures with clear technical errors and failed synthetic ligaments. METHODS Between 2015 and 2022, 130 patients with failed ACLR were retrospectively identified; 79 knees with adequate MRI scans were analyzed. These were compared to 57 non-failed ACLRs. MRI measurements included lateral and medial tibial bony slope (LBS, MBS) and lateral and medial meniscal slope (LMS, MMS). Subgroup analysis assessed for failures with technical errors and failed synthetic ligaments. RESULTS In all patients, the LMS and MMS reduced the bony slope towards the horizontal without reaching statistical significance. Failed ACLR had significantly higher MBS (7.1° ± 2.9 vs. 4.6° ± 2.5, p < 0.001) and MMS (5.6° ± 3.5 vs. 3.4° ± 2.8, p < 0.001). The area under the curve for MBS was 0.721 (CI: 0.628-0.813). The Youden optimal threshold value of MBS ≥ 5.1° (sensitivity 80 %, specificity 56.1 %) yielded an odd's ratio for failure of 5.1 (CI:2.3-11.6; p < 0.001). Revisions with technical errors had slopes that were not significantly different to non-failed ACLR. Revisions with synthetic grafts had MBS (7.3° ± 3.2 vs. 4.6° ± 2.5; p = 0.007) and MMS (6° ± 3.8 vs. 3.4° ± 2.8; p = 0.021) that were significantly higher to non-failed ACLR. CONCLUSION Medial bony and meniscal slopes are higher in patients with unexplained failed ACLRs and revisions with synthetic grafts, but ACLR with technical errors failed with slopes similar to non-failed ACLRs. Increased medial slope values are a risk factor for surgical failure. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Anna-Katharina Calek
- Melbourne Orthopaedic Group, 33 The Avenue, Windsor, 3181 Melbourne, VIC, Australia; Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008 Zurich, Switzerland.
| | - Bettina Hochreiter
- Melbourne Orthopaedic Group, 33 The Avenue, Windsor, 3181 Melbourne, VIC, Australia; Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008 Zurich, Switzerland.
| | - Samuel J Ek
- Melbourne Orthopaedic Group, 33 The Avenue, Windsor, 3181 Melbourne, VIC, Australia.
| | - Ashley Carr
- Melbourne Orthopaedic Group, 33 The Avenue, Windsor, 3181 Melbourne, VIC, Australia.
| | - David Young
- Melbourne Orthopaedic Group, 33 The Avenue, Windsor, 3181 Melbourne, VIC, Australia.
| | - Jonathan Baré
- Melbourne Orthopaedic Group, 33 The Avenue, Windsor, 3181 Melbourne, VIC, Australia.
| | - Timothy D Lording
- Melbourne Orthopaedic Group, 33 The Avenue, Windsor, 3181 Melbourne, VIC, Australia.
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Farid AR, Pradhan P, Stearns SA, Kocher MS, Fabricant PD. Association Between Posterior Tibial Slope and ACL Injury in Pediatric Patients: A Systematic Review and Meta-analysis. Am J Sports Med 2024; 52:2911-2918. [PMID: 38275009 DOI: 10.1177/03635465231199649] [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: 01/27/2024]
Abstract
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.
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Affiliation(s)
| | - Pratik Pradhan
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Mininder S Kocher
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Peter D Fabricant
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Shin CH, Syed AN, Swanson ME, Kushare IV, Shea KG, ASTEROID;, Ganley TJ, Contributing members of ASTEROID:, Baghdadi S, Cruz AI, Ellis HB, Fabricant PD, Ganley TJ, Green DW, Kerrigan A, Kirby J, Kocher M, Kushare IV, Jay Lee R, MacDonald JP, McKay SD, Parikh SN, Patel NM, Yen YM, Schmale GA, Shea KG, Justin Mistovich R. Evaluation of Tibial Slope on Radiographs in Pediatric Patients With Tibial Spine Fractures: An Age- and Sex-Matched Study. Orthop J Sports Med 2024; 12:23259671241256445. [PMID: 39100212 PMCID: PMC11295229 DOI: 10.1177/23259671241256445] [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: 02/13/2024] [Accepted: 04/02/2024] [Indexed: 08/06/2024] Open
Abstract
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.
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Affiliation(s)
- Chang Ho Shin
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Akbar N. Syed
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Morgan E. Swanson
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Indranil V. Kushare
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kevin G. Shea
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - ASTEROID;
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Theodore J. Ganley
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Soroush Baghdadi
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Aristides I. Cruz
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Henry B. Ellis
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Peter D. Fabricant
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Theodore J. Ganley
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Daniel W. Green
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alicia Kerrigan
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julia Kirby
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mininder Kocher
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Indranil V. Kushare
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - R. Jay Lee
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James P. MacDonald
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Scott D. McKay
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shital N. Parikh
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Neeraj M. Patel
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yi-Meng Yen
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Gregory A. Schmale
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kevin G. Shea
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - R. Justin Mistovich
- Investigation performed at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Feroe AG, Hassan MM, Kocher MS. Physeal-Sparing Anterior Cruciate Ligament Reconstruction with Iliotibial Band Autograft in the Skeletally Immature Knee. Arthrosc Tech 2022; 11:e1597-e1603. [PMID: 36185112 PMCID: PMC9520009 DOI: 10.1016/j.eats.2022.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/14/2022] [Indexed: 02/03/2023] Open
Abstract
Conventional adult anterior cruciate ligament reconstruction techniques are controversial in skeletally immature patients due to the risk of iatrogenic physeal damage and potential growth disturbance. The physeal-sparing, combined intra- and extra-articular anterior cruciate ligament reconstruction using an autogenous iliotibial band was developed to mitigate this risk in prepubescent, skeletally immature patients, with excellent functional outcomes and a low revision rate. This article describes the surgical details of this reproducible reconstruction technique.
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Affiliation(s)
- Aliya G. Feroe
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children’s Hospital, Boston, Massachusetts, U.S.A
- Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Mahad M. Hassan
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A
- TRIA Orthopaedic Center, Bloomington, Minnesota, U.S.A
| | - Mininder S. Kocher
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children’s Hospital, Boston, Massachusetts, U.S.A
- Harvard Medical School, Boston, Massachusetts, U.S.A
- Address correspondence to Mininder S. Kocher, M.D., M.P.H., Boston Children’s Hospital, Orthopaedic Surgery & Sports Medicine, 300 Longwood Ave., Boston, MA 02115, U.S.A.
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Jeong HW, Kim JS, Nam HS, Noh GS, Lee YS. Assessment of Anatomic Restoration and Clinical Outcomes Between Medial and Lateral Meniscal Allograft Transplantation. Orthop J Sports Med 2022; 10:23259671221113280. [PMID: 36105654 PMCID: PMC9465589 DOI: 10.1177/23259671221113280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/16/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Proper anatomic restoration is an important consideration for meniscal
allograft transplantation (MAT), even with the different anatomica
characteristics between the medial meniscus and lateral meniscus. Purpose/Hypothesis: The purpose of this study was to assess the accuracy of anatomic restoration
in medial and lateral MAT (MMAT and LMAT) procedures and to compare their
outcomes. We hypothesized that (1) the anatomic differences between the
medial and lateral menisci will mean a less accurate anatomic restoration
for MMAT and (2) clinical outcomes after MMAT will be inferior compared with
LMAT. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively evaluated 20 patients who underwent MMAT using the bone
plug technique and 21 patients who underwent LMAT using the keyhole
technique at a single institution from July 2014 to June 2019. Demographic
data, previous surgeries, and concomitant procedures were recorded, as were
lower limb alignment and osteoarthritis grade on radiographs. Using
preoperative and follow-up magnetic resonance imaging, the meniscal
position, rotation, extrusion, and intrameniscal signal intensity were
evaluated. Clinical outcomes were evaluated using the International Knee
Documentation Committee and Lysholm scores. Results: The mean follow-up was 41.15 ± 18.86 and 45.43 ± 21.32 months for the MMAT
and LMAT patients, respectively. Concomitant procedures were performed in
90% of MMATs and 15% of LMATs. There was no significant difference between
the native and postoperative root positions after LMAT; however, for MMAT,
the position of the anterior root was located significantly posteriorly
(P = .002) and medially (P = .007)
compared with preoperatively. In addition, the allograft medial meniscus was
restored in a more internally rotated position (P = .029).
MMATs also exhibited significantly increased meniscal extrusion compared
with LMATs (posterior horn, P < .001; midbody,
P = .027; anterior horn, P = .006).
However, there was no significant difference between the 2 groups at final
follow-up in intrameniscal signal intensity or clinical scores. Conclusion: LMAT showed higher accuracy than MMAT in restoring meniscal position and
rotation, and there was less meniscal extrusion. However, clinical scores
improved after both LMAT and MMAT compared with preoperative values, and
midterm clinical outcomes were similar. The small anatomical errors seen in
the MMAT technique were not clinically relevant at midterm follow-up.
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Affiliation(s)
- Ho Won Jeong
- Department of Orthopaedic Surgery, Seoul National University College
of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of
Korea
| | - Joo Sung Kim
- Department of Orthopaedic Surgery, Seoul National University College
of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of
Korea
| | - Hee Seung Nam
- Department of Orthopaedic Surgery, Seoul National University College
of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of
Korea
| | - Gwon Seok Noh
- Department of Orthopaedic Surgery, Seoul National University College
of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of
Korea
| | - Yong Seuk Lee
- Department of Orthopaedic Surgery, Seoul National University College
of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of
Korea
- Yong Seuk Lee, MD, PhD, Department of Orthopaedic Surgery, Seoul
National University College of Medicine, Bundang Hospital, 82, Gumi-ro
173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea (
,
)
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9
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Dean RS, DePhillipo NN, LaPrade RF. Posterior Tibial Slope in Patients With Torn ACL Reconstruction Grafts Compared With Primary Tear or Native ACL: A Systematic Review and Meta-analysis. Orthop J Sports Med 2022; 10:23259671221079380. [PMID: 35425846 PMCID: PMC9003651 DOI: 10.1177/23259671221079380] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 11/30/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Increased posterior tibial slope (PTS) is a risk factor for anterior cruciate ligament (ACL) rupture and failure of ACL reconstruction (ACLR) grafts. Purpose: The purpose was to conduct a systematic review of literature on PTS measurements and to conduct a meta-analysis of comparable PTS measurements based on a patient’s ACL status. It was hypothesized that patients with torn ACLR grafts would have significantly larger medial and lateral PTS compared with patients with native ACLs or those who underwent primary ACLR. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were studies that reported medial and/or lateral PTS measurements, those that reported PTS measurements based on ACL status (ie, intact ACL, primary ACL tear, failed ipsilateral ACLR, or revision ACLR), and those that reported their specific PTS measurement technique. Average PTS measurements, measurement location (medial or lateral tibial plateau) and technique, imaging modality used, and ACL status were extracted from each study. Data were pooled using DerSimonian and Laird random-effects models, and results were compared using the Altman interaction test. Results: The literature search identified 1705 studies, of which 82 (N = 12,971 patients) were included. There were 4028 patients in the intact ACL group (31%), 7405 in the primary ACLR group (57%), and 1538 in the failed ACLR group (12%). Measurements were obtained from lateral radiographs in 31 studies (38%), from magnetic resonance imaging in 47 studies (57%), and from computed tomography in 4 studies (5%). The failed ACLR group had a significantly larger lateral PTS (9.55°; 95% CI, 8.47°-10.63°) than either the primary ACL tear (7.13°; 95% CI, 6.58°-7.67°) or intact ACL (5.57°; 95% CI, 5.03°-6.11°) groups (P < .001 for both). The failed ACLR group also had a significantly larger medial PTS (9.05°; 95% CI, 7.80°-10.30°) than the primary (6.24°; 95% CI, 5.71°-6.78°) or intact ACL (6.28°; 95% CI, 5.21°-7.35°) groups (P < .001 for both). Conclusion: Both lateral and medial PTS measurements were greater in patients who had failed previous ACLR than those with a primary ACL tear or an intact native ACL. The lateral PTS of patients with primary ACL tears was greater than those with an intact native ACL.
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Affiliation(s)
- Robert S. Dean
- Beaumont Health, Royal Oak, Michigan, USA
- Twin Cities Orthopedics, Edina, Minnesota, USA
| | - Nicholas N. DePhillipo
- Twin Cities Orthopedics, Edina, Minnesota, USA
- Oslo Sports Trauma Research Center, Oslo, Norway
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10
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Editorial Commentary: Increased Tibial Slope Is Associated With Anterior Cruciate Ligament Injury Risk, and Tibial Slope Increases in the Skeletally Immature, Anterior Cruciate Ligament-Deficient Knee: A Chicken or Egg Causality Dilemma? Arthroscopy 2021; 37:2589-2590. [PMID: 34353562 DOI: 10.1016/j.arthro.2021.04.047] [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: 04/16/2021] [Accepted: 04/16/2021] [Indexed: 02/02/2023]
Abstract
Increased tibial slope is associated with increased risk of anterior cruciate ligament (ACL) injury in the skeletally immature. Recent studies, however, emphasize a mutual influence, as tibial slope has been shown to increase over time in the ACL-deficient skeletally immature knee. It is hypothesized that altered biomechanics with enhanced posterior force transmission in the ACL-deficient knee may influence the developing physis, leading to altered longitudinal growth and increased tibial slope. In addition to tibial slope, the meniscal geometry, including meniscal bone angle and meniscal slope, have been shown to influence the risk of ACL injury. In the skeletally immature knee, especially, the soft tissue geometry is thought to have significant impact on ACL injury risk. However, it remains unknown whether alteration of the meniscal slope may represent a causality of ACL deficiency.
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