|
1
|
Veerman QWT, Ten Heggeler RM, Tuijthof GJM, de Graaff F, Fluit R, Hoogeslag RAG. High variability exists in 3D leg alignment analysis, but underlying principles that might lead to agreement on a universal framework could be identified: A systematic review. Knee Surg Sports Traumatol Arthrosc 2025; 33:2063-2077. [PMID: 39460613 DOI: 10.1002/ksa.12512] [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: 05/21/2024] [Revised: 09/22/2024] [Accepted: 09/23/2024] [Indexed: 10/28/2024]
Abstract
PURPOSE To (1) investigate the hypothesis that there is high variability in the reported methods to derive axes and joint orientations from three-dimensional (3D) bone models to (a) perform 3D knee-related leg alignment analysis and (b) define coordinate systems for the femur, tibia and leg and (2) identify underlying principles that might lead to agreement on a universal 3D leg alignment analysis framework. METHODS A systematic review of the literature between January 2006 and June 2024 was performed. Articles explicitly reporting methods to derive axes and joint orientations from CT-based 3D bone models for alignment parameters and/or coordinate systems of the femur, tibia and leg were included. Study characteristics and reported methods were extracted and presented as a qualitative synthesis. RESULTS A total of 93 studies were included. There was high variability in the reported methods to derive axes and joint orientations from 3D bone models. Nevertheless, the reported methods could be categorized into four groups, and several underlying principles of the four groups could be identified. Furthermore, the definitions of femoral and tibial coordinate systems were most frequently based on the mechanical axis (femoral, 13/19 [68%]; tibial, 13/26 [50%]) and a central medial-lateral axis (femoral, 16/19 [84%]; tibial, 12/26 [46%]); no leg coordinate system was reported. Interestingly, of the included studies that reported on leg alignment parameters (76/93, 82%), only a minority reported expressing these in a complete coordinate system (25/76, 33%). CONCLUSION There is high variability in 3D knee-related leg alignment analysis. Therefore, universal 3D reference values for alignment parameters cannot yet be defined, and comparison of alignment parameter values between different studies is impossible. However, several underlying principles to the reported methods were identified, which could serve to reach more agreement on a future universal 3D framework for leg alignment analysis. LEVEL OF EVIDENCE Level I.
Collapse
Affiliation(s)
- Quinten W T Veerman
- OCON Centre for Orthopaedic Surgery and Sports Medicine, Hengelo, the Netherlands
- Faculty of Engineering Technology, University of Twente, Enschede, the Netherlands
| | - Romy M Ten Heggeler
- OCON Centre for Orthopaedic Surgery and Sports Medicine, Hengelo, the Netherlands
- Faculty of Engineering Technology, University of Twente, Enschede, the Netherlands
| | | | - Feike de Graaff
- OCON Centre for Orthopaedic Surgery and Sports Medicine, Hengelo, the Netherlands
| | - René Fluit
- Faculty of Science and Engineering, University of Groningen, Groningen, the Netherlands
| | - Roy A G Hoogeslag
- OCON Centre for Orthopaedic Surgery and Sports Medicine, Hengelo, the Netherlands
| |
Collapse
|
|
2
|
Lemme NJ, Badida R, Molino J, Quinn M, Hague M, Fleming BC, Owens BD. The Effect of Lateral Extra-articular Tenodesis on Anterior Cruciate Ligament Graft Forces and Knee Stability Compared With Slope Reduction Osteotomy in the Setting of Increased Posterior Tibial Slope. Am J Sports Med 2025:3635465251338236. [PMID: 40396207 DOI: 10.1177/03635465251338236] [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: 05/22/2025]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction (ACLR) in the presence of excessive posterior tibial slope (PTS) is a well-established risk factor for increased ACL graft forces and a heightened risk of graft failure. PURPOSE/HYPOTHESIS The primary aim of this study was to evaluate whether lateral extra-articular tenodesis (LET) could mitigate the adverse effects of increased PTS on knee kinematics and ACL graft forces, achieving results comparable to those of slope-reducing osteotomy (SRO). It was hypothesized that LET would provide similar improvements in knee stability and graft force reduction to SRO in the presence of increased PTS. A secondary aim was to determine if an ALC injury exacerbates the effect of increased PTS on ACL graft forces and overall knee stability. It was hypothesized that ALC injury would amplify the negative effects of increased PTS. STUDY DESIGN Controlled laboratory study. METHODS Eight fresh-frozen cadaveric specimens were prepared, excluding those with previous surgery or significant knee pathology. ACLR was performed using a quadrupled hamstring tendon autograft. The effects of LET and SRO were tested at various degrees of PTS (0°, 10°, and 20°). A simulated pivot-shift maneuver was used to measure ACL graft loads, anterior tibial translation (ATT), and internal rotation (IR). Mixed-effects models were utilized to analyze the data. RESULTS Increasing PTS resulted in significant increases in ACL graft forces (P < .001), ATT (P < .001), and IR (P < .001). LET reduced ACL graft loads by 22.1% at 10° and 36.6% at 20° of PTS. In contrast, a 10° SRO showed only a 2.6% reduction at 10° and 23.9% at 20° of PTS. There were no significant differences in graft forces between the postosteotomy states and LET augmentation states at both 10° and 20° of tibial slope, suggesting equivalent efficacy in reducing graft loads. Additionally, LET significantly decreased graft forces compared with the ALC-sectioned state (P = .019). Finally, ALC sectioning did not significantly increase ACL graft load compared with the ACLR-only condition (P = .320), nor did it exacerbate the effects of increased PTS on ATT and IR. CONCLUSION LET effectively reduces ACL graft forces and improves knee stability in the presence of increased PTS, performing comparably to or better than SRO under simulated pivot-shift conditions. CLINICAL RELEVANCE These findings suggest that LET is a viable alternative to SRO, particularly for patients with high PTS undergoing ACLR.
Collapse
Affiliation(s)
- Nicholas J Lemme
- Department of Orthopaedics, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Rohit Badida
- Department of Orthopaedics, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Janine Molino
- Department of Orthopaedics, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Matthew Quinn
- Department of Orthopaedics, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Madalyn Hague
- Department of Orthopaedics, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Brett D Owens
- Department of Orthopaedics, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| |
Collapse
|
|
3
|
Mansour A, Aboulafia A, Lemaster N, Dziuba J, Gattu N, Anz H, Brooks W, Rodriguez J, Lowe W. A Novel Assessment of Sagittal Proximal Tibial Morphology and Relationship to Proximal Posterior Tibial Slope: Lateral Supratubercle Angle. Am J Sports Med 2025; 53:1392-1399. [PMID: 40230304 PMCID: PMC12044208 DOI: 10.1177/03635465251331005] [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: 09/12/2024] [Accepted: 02/14/2025] [Indexed: 04/16/2025]
Abstract
BACKGROUND Multiple techniques have been utilized to measure posterior tibial slope (PTS) without consensus on which imaging modality, view, and axis combination is most consistent for risk assessment and preoperative planning in primary and revision anterior cruciate ligament (ACL) surgery. An exclusively proximal-based measurement of PTS has yet to be defined. PURPOSE/HYPOTHESIS The purpose of this study was to establish normal values for novel measurements of sagittal proximal tibial morphology, the lateral supratubercle angle (LSTA) and the lateral supratubercle distance (LSTD), in normative and primary ACL tear cohorts. The secondary aim was to establish cutoff values and determine if these tibial measurement values are predictive of the presence of an ACL tear. It was hypothesized that LSTA will be significantly different between cohorts. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS The medical records of patients with a knee complaint between August 2016 and June 2024 were retrospectively reviewed, and the patients were placed into either the normative or primary ACL tear cohort. Three independent observers measured LSTA, LSTD, and PTS along both the lateral (L) and medial (M) tibial plateaus on standard lateral knee radiographs. Means were calculated for each measurement and compared between groups. The receiver operating characteristic curve was used to determine the sensitivity and specificity of significant measurements. RESULTS Significant differences were found between normative (n = 150) and primary ACL tear (n = 150) groups in LSTA-L (normative: 9.9°± 4.4° vs primary ACL tear: 11.1°± 4.4°; P = .02), LSTA-M (normative: 10.3°± 4.4° vs ACL tear: 11.4°± 4.6°; P = .03), and PTS-M (normative: 9.2°± 3.2° vs primary ACL tear: 10.0°± 3.1°; P = .03). CONCLUSION Mean values and ranges for LSTA and LSTD have been established in normative and primary ACL tear cohorts. LSTA-L, LSTA-M, and PTS-M significantly differed between the cohorts. Future studies with LSTA will evaluate the utilization of these proximal tibial deformity-based measurements in ACL surgery, retear risk assessment, and slope-reducing osteotomy planning.
Collapse
Affiliation(s)
- Alfred Mansour
- University of Texas Health Science Center at Houston, Department of Orthopaedic Surgery, McGovern Medical School, Houston, Texas, USA
| | - Alexis Aboulafia
- University of Texas Health Science Center at Houston, Department of Orthopaedic Surgery, McGovern Medical School, Houston, Texas, USA
| | - Nicole Lemaster
- Memorial Hermann Rockets Sports Medicine Institute, Houston, Texas, USA
| | - Jessica Dziuba
- University of Texas Health Science Center at Houston, Department of Orthopaedic Surgery, McGovern Medical School, Houston, Texas, USA
| | - Nikhil Gattu
- University of Texas Health Science Center at Houston, Department of Orthopaedic Surgery, McGovern Medical School, Houston, Texas, USA
| | - Hayden Anz
- University of Texas Health Science Center at Houston, Department of Orthopaedic Surgery, McGovern Medical School, Houston, Texas, USA
| | - William Brooks
- University of Texas Health Science Center at Houston, Department of Orthopaedic Surgery, McGovern Medical School, Houston, Texas, USA
| | - Jaremy Rodriguez
- University of Texas Health Science Center at Houston, Department of Orthopaedic Surgery, McGovern Medical School, Houston, Texas, USA
| | - Walter Lowe
- University of Texas Health Science Center at Houston, Department of Orthopaedic Surgery, McGovern Medical School, Houston, Texas, USA
| |
Collapse
|
|
4
|
Hunter CD, Rosenthal RM, Froerer DL, Ihn HE, Khalil AZ, Featherall J, Ernat JJ, Maak TG, Aoki SK. Measuring Posterior Tibial Slope: A Comparison Using a 10-cm Anatomic Axis Versus 15-cm Anatomic Axis. Orthop J Sports Med 2025; 13:23259671251335982. [PMID: 40416993 PMCID: PMC12099164 DOI: 10.1177/23259671251335982] [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: 12/03/2024] [Accepted: 01/06/2025] [Indexed: 05/27/2025] Open
Abstract
Background Accurate measurement of posterior tibial slope (PTS) is for understanding knee biomechanics and stability, as well as in planning surgical procedures. The validated methodology for measuring PTS requires outline visualization of 15 cm distal to the proximal tibia, a cutoff that is not always met on standard lateral knee radiographs. Purpose/Hypothesis The goal of this study was to critically evaluate whether using a 10-cm anatomic axis on conventional lateral knee radiographs is comparable with the established 15-cm standard. The authors hypothesized that a shortened 10-cm anatomic axis would yield comparable results to the conventional 15-cm method. Study Design Cohort study (diagnosis); Level of evidence, 3. Methods Lateral knee radiographs were reviewed until a cohort of 100 patients was identified where ≥15 cm of the tibial shaft distal to the joint line could be measured. PTS was calculated using both the conventional 15-cm proximal anatomic axis (15-PTS) and the proposed modified 10-cm axis (10-mPTS). Measurement reliability and agreement were quantitatively assessed via intraclass correlation coefficients (ICCs) and Bland-Altman analysis, respectively. Paired t tests and linear regression were performed to evaluate the equivalence of methods. Additionally, a second set of 100 lateral knee radiographs was randomly selected to determine a percentage of radiographs that could be measured ≥15 cm below the joint line. Results There was a statistically significant congruence between the 10-mPTS and 15-PTS techniques (ICC, 0.92; P < .001). The mean PTS discrepancy was statistically significant at 0.94°, with a 95% CI ranging from 0.78° to 1.0°. Both methods demonstrated high inter- and intrarater reliability (ICCs > 0.90). On 61% of standard lateral knee radiographs queried, we were unable to visualize 15 cm of the proximal tibia. Conclusion The 10-mPTS method exhibits <1° of deviation compared with the conventional 15-PTS approach, establishing it as a practical and reliable alternative for assessing PTS on lateral knee radiographs, particularly when visualization of 15 cm distally is not possible.
Collapse
Affiliation(s)
- Collin D.R. Hunter
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Reece M. Rosenthal
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Devin L. Froerer
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Hansel E. Ihn
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Ameen Z. Khalil
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Joseph Featherall
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Justin J. Ernat
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Travis G. Maak
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Stephen K. Aoki
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
|
5
|
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.
Collapse
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
| |
Collapse
|
|
6
|
Kennedy NI, DePhillipo NN, Tollefson LV, LaPrade RF. Knee osteotomies are becoming widely accepted and increasingly used, but rehabilitation techniques still vary widely between surgeons: A survey on current trends. J Exp Orthop 2025; 12:e70270. [PMID: 40421407 PMCID: PMC12104822 DOI: 10.1002/jeo2.70270] [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: 02/18/2025] [Revised: 03/20/2025] [Accepted: 03/31/2025] [Indexed: 05/28/2025] Open
Abstract
Purpose The purpose of this research survey was to report the current trends regarding the frequency, indications and techniques of knee osteotomies used in sports medicine practices over the past 5 years and during fellowship training. Methods Two Institutional Review Board-exempt anonymous surveys were electronically distributed between May 2023 and August 2023. A 19-question survey was sent to active members of the American Orthopaedic Society for Sports Medicine and European Society of Sports Traumatology, Knee Surgery and Arthroscopy societies and another 36-question survey was sent to orthopaedic sports medicine fellows near the end of their training. The surveys included questions regarding type and frequency of osteotomies performed, surgical indications, surgical techniques, preoperative planning and post-operative weight-bearing restrictions. Inclusion criteria were those who currently perform knee osteotomy surgery. Descriptive statistics were used for all comparisons. Results A total of 100 sports medicine surgeons and 26 sports medicine fellows participated in the survey. The most common type of osteotomy performed was a medial opening-wedge proximal tibial osteotomy for both surgeons (96%) and fellows (92%). The most used methods to assess coronal and sagittal alignment were long-leg radiographs (98% for surgeons) and lateral radiographs (66% for surgeons), respectively. Rehabilitation techniques varied between surgeons and fellows and depended on the technique, size of correction and hardware. Conclusion Osteotomies are becoming widely accepted as useful techniques to correct bony malalignment. Surgeons are increasing their use of osteotomies, and fellows in training are optimistic about the use of new technologies for osteotomy planning and execution. Trends suggest that osteotomies to correct varus and valgus malalignment for osteoarthritis are the most common, and rehabilitation techniques vary widely between surgeons. Level of Evidence Level V.
Collapse
Affiliation(s)
- Nicholas I. Kennedy
- Department of OrthopedicsTwin Cities OrthopedicsEdinaMinnesotaUSA
- Multicare Orthopedics NorthwestYakimaWashingtonUSA
| | | | | | | |
Collapse
|
|
7
|
Yang F, Yokoe T, Ouchi K, Tajima T, Kamei N, Chosa E. Biomechanical effects of LCWHTO vs. MOWHTO on medial meniscus posterior root repair: a finite element analysis. Sci Rep 2025; 15:10008. [PMID: 40122952 PMCID: PMC11930934 DOI: 10.1038/s41598-025-94965-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2024] [Accepted: 03/18/2025] [Indexed: 03/25/2025] Open
Abstract
Whether isolated high tibial osteotomy (HTO) or HTO combined with medial meniscus posterior root (MMPR) repair is the optimal surgical treatment of MMPR tears remains controversial. This study compared the biomechanical effects of isolated HTO versus MMPR repair combined with medial open wedge HTO (MOWHTO) or lateral closed wedge HTO (LCWHTO) using finite element analysis (FEA). In this study, the MRI and CT data of the knee joint were used to create an FEA model. MOWHTO and LCWHTO simulations adjusted the mechanical axis to the Fujisawa point, with MMPR conditions simulated as intact, tear, or repaired. The ankle center was fixed and a 1000 N force was applied to the knee. In the LCWHTO models, the posterior tibial slope (PTS) decreased, whereas it increased in the MOWHTO models. Changes in the PTS following HTO influenced the stress distribution in the MMPR. HTO combined with MMPR repair showed a reduction in the maximum contact stress by 5.4-11.4% and increased contact area by 29.5-41.0% in the medial knee compartment relative to isolated HTO. This study demonstrated that MMPR repair combined with LCWHTO would be more protective against stress loading in the MMPR than MMPR repair combined with MOWHTO or isolated HTO.
Collapse
Affiliation(s)
- Fan Yang
- Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, 889-1692, Miyazaki, Japan
- Department of Orthopaedics Surgery, Qinghai University Affiliated Hospital, Xining, 810000, Qinghai, China
| | - Takuji Yokoe
- Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, 889-1692, Miyazaki, Japan.
| | - Koki Ouchi
- Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, 889-1692, Miyazaki, Japan
| | - Takuya Tajima
- Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, 889-1692, Miyazaki, Japan
| | - Naosuke Kamei
- Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, 889-1692, Miyazaki, Japan
| | - Etsuo Chosa
- Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, 889-1692, Miyazaki, Japan
| |
Collapse
|
|
8
|
Ollivier M, Hoffer AJ, Onishi S, Brilhault J, Frey-Ollivier S, Godshaw B, Kley K. Slope-Reducing Tibial Plateau-Leveling Osteotomy. Arthrosc Tech 2025; 14:103264. [PMID: 40207317 PMCID: PMC11977168 DOI: 10.1016/j.eats.2024.103264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Accepted: 08/18/2024] [Indexed: 04/11/2025] Open
Abstract
Increased posterior tibial slope (PTS) is a risk factor for anterior cruciate ligament (ACL) tear and ACL reconstruction failure. Anterior closing-wedge osteotomy (ACWO) decreases the PTS and the risk of reinjury after revision ACL reconstruction. ACWO techniques include supratubercular, transtubercular, or infratubercular. However, there are limitations to the amount of slope correction an ACWO can achieve in the context of a massively abnormal slope. If the necessary slope correction is greater than 20°, a supratubercular ACWO cannot achieve the required correction without high risk of brittle fixation, a transtubercular ACWO would introduce increased morbidity of a secondary osteotomy and change the biomechanics of the patellofemoral joint resulting in significant patella alta, and an infratubercular ACWO would require a major anterior tibial metaphysodiaphyseal resection. The tibial plateau leveling osteotomy (TPLO) is an alternative curved osteotomy commonly used in canines that avoids the adverse events associated with a large ACWO. Further benefits of TPLO for massive slope correction include improved maintenance of native soft-tissue tension, avoidance of major recurvatum, and the ability to control the correct degree. We describe an open technique for a TPLO to decrease the PTS and the risk of recurrent ACL injury.
Collapse
Affiliation(s)
- Matthieu Ollivier
- Institute of Movement Sciences, Sainte-Marguerite Hospital, Aix-Marseille University, Marseille, France
| | - Alexander J. Hoffer
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
| | - Shintaro Onishi
- Institute of Movement Sciences, Sainte-Marguerite Hospital, Aix-Marseille University, Marseille, France
- Department of Orthopaedic Surgery, Hyogo College of Medicine, Hyōgo, Japan
| | - Jean Brilhault
- Centre Cheville & Pied, Clinique St Léonard, Trélazé, France
| | | | - Brian Godshaw
- Ochsner Andrews Sports Medicine Institute, New Orleans, Louisiana, U.S.A
| | - Kristian Kley
- Orthopaedic Care Center, Harley Street Specialist Hospital, London, England
| |
Collapse
|
|
9
|
Blackman B, Sidhu MS, Shah A, Mann J, Marks P, Wasserstein D. Guided Growth for Posterior Tibial Slope Correction Followed by ACL Reconstruction in an Adolescent Male: A Case Report. JBJS Case Connect 2025; 15:01709767-202503000-00051. [PMID: 39977547 DOI: 10.2106/jbjs.cc.24.00536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2025]
Abstract
CASE A 13-year-old adolescent boy presented with chronic anterior cruciate ligament (ACL) insufficiency and prior medial meniscectomy. Radiographic evaluation revealed a posterior tibial slope (PTS) of 20°, putting him at high risk of reinjury following ACL reconstruction (ACLR). Guided growth using anteriorly placed eight plates was used for 9 months, which reduced his PTS to 6°. Two months following plate removal, the patient underwent ACLR with lateral extra-articular tenodesis. CONCLUSION This previously proposed but never reported approach suggests that guided growth is a viable option to correct excessive PTS before ACLR in skeletally immature patients.
Collapse
Affiliation(s)
- Benjamin Blackman
- Orthopaedic Division, Department of Surgery, Sunnybrook Health Sciences, Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Manpreet Singh Sidhu
- Orthopaedic Division, Department of Surgery, Sunnybrook Health Sciences, Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ajay Shah
- Orthopaedic Division, Department of Surgery, Sunnybrook Health Sciences, Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jennah Mann
- Division of Orthopaedic Surgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Paul Marks
- Orthopaedic Division, Department of Surgery, Sunnybrook Health Sciences, Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David Wasserstein
- Orthopaedic Division, Department of Surgery, Sunnybrook Health Sciences, Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
|
10
|
Mayer P, Hielscher L, Schuster P, Schlumberger M, Rolvien T, Geßlein M, Beel W, Richter J. Evaluating the Mechanical Axis for Detection of Posterior Tibial Slope Malalignment in ACL-Deficient Knees on Lateral Radiographs. Orthop J Sports Med 2025; 13:23259671241296858. [PMID: 39877421 PMCID: PMC11773544 DOI: 10.1177/23259671241296858] [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: 07/19/2024] [Accepted: 07/30/2024] [Indexed: 01/31/2025] Open
Abstract
Background Distal tibial deformities are not assessed using the proximal anatomical axis (PAA) to determine the posterior tibial slope (PTS). Therefore, it seems advantageous to measure PTS on full-length lateral tibial radiographs using the mechanical axis (MA). Purposes To (1) compare the PTS measurements using the MA and the PAA and (2) determine whether using the PAA fails to detect a certain number of significantly elevated PTS values compared with using the MA. Study Design Cohort study (Diagnosis); Level of evidence, 3. Methods Full-length lateral tibial radiographs of 218 consecutive cases were reviewed. Radiographs were checked for malrotation. Therefore, the distance between the posterior tibial condyles was measured in millimeters. Patients with a difference of ≥7 mm between the posterior tibial condyles were excluded, leaving 196 cases for the final statistical analysis. The PTS was measured using the MA and the PAA. Differences between these 2 techniques were analyzed. The sensitivity and specificity of the PAA as a screening method for pathological PTS were calculated, with the MA as the standard for comparison. Four subgroups were formed, all with PAA <12° and different lower limits for the MA: group 1, MA ≥10°; group 2, MA ≥10.5°; group 3, MA ≥11°; and group 4, MA ≥11.5°. Results Radiographs with ≥7 mm between the posterior tibial condyles showed an increased inconsistency between the PTS measurement with the MA and the PAA. In the group with a distance of <7 mm between the posterior tibial condyles (n = 196), the mean PTS measured with the MA was 9.4°± 3.8° (range, 0.4° to 21.9°), and the mean PTS was 10.5°± 3.5° (range, 1.7° to 20.9°) according to the PAA. The mean difference in PTS between the PAA and the MA was 1.1°± 1.2° (range, -2.4° to 4.1°; P < .001). Group 1 had a sensitivity of 73% and specificity of 98%; group 2, sensitivity of 84% and specificity of 97%; group 3, sensitivity of 87% and specificity of 93%; and group 4, sensitivity of 95% and specificity of 89%. Conclusion Measuring the PTS using the MA was advantageous, as the measurement with the PAA did not correctly identify all cases with sagittal alignment changes. The proportion of patients with pathologically increased PTS not identified with the proximal anatomical measurement, reflected by the sensitivity, depended on the threshold value defined for the MA. Lateral radiographs, showing an increased distance between the posterior tibial condyles, indicated malrotation of the tibia leading to measurement inaccuracy.
Collapse
Affiliation(s)
- Philipp Mayer
- Orthopedic Hospital Markgroeningen, Centre for Sports Orthopaedics and Special Joint Surgery, Markgroeningen, Germany
- Department of Orthopaedics and Traumatology, Paracelsus Medical University, Clinic Nuremberg, Nuremberg, Germany
- Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft)
| | - Lotta Hielscher
- Department of Orthopaedics and Traumatology, Paracelsus Medical University, Clinic Nuremberg, Nuremberg, Germany
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Schuster
- Orthopedic Hospital Markgroeningen, Centre for Sports Orthopaedics and Special Joint Surgery, Markgroeningen, Germany
- Department of Orthopaedics and Traumatology, Paracelsus Medical University, Clinic Nuremberg, Nuremberg, Germany
- Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft)
| | - Michael Schlumberger
- Orthopedic Hospital Markgroeningen, Centre for Sports Orthopaedics and Special Joint Surgery, Markgroeningen, Germany
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Geßlein
- Department of Orthopaedics and Traumatology, Paracelsus Medical University, Clinic Nuremberg, Nuremberg, Germany
| | - Wouter Beel
- Orthopedic Hospital Markgroeningen, Centre for Sports Orthopaedics and Special Joint Surgery, Markgroeningen, Germany
| | - Jörg Richter
- Orthopedic Hospital Markgroeningen, Centre for Sports Orthopaedics and Special Joint Surgery, Markgroeningen, Germany
| |
Collapse
|
|
11
|
Dracic A, Zeravica D, Zovko I, Jäger M, Beck S. Cut-off value for the posterior tibial slope indicating the risk for retear of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39641394 DOI: 10.1002/ksa.12552] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 11/10/2024] [Accepted: 11/17/2024] [Indexed: 12/07/2024]
Abstract
PURPOSE The significance of the posterior tibial slope (PTS) has increasingly come into focus in anterior cruciate ligament (ACL) reconstruction being a risk factor for ACL graft failure. Nevertheless, inconsistent data on the critical value of the PTS exist. The purpose of this study was to define a cut-off value for the PTS in ACL surgery. METHODS In a retrospective cohort study, 350 revision ACL reconstructions (ACL-RR) with a failed ACL hamstring graft and 350 primary ACL reconstructions (ACL-R) were matched according to age, gender, concomitant injuries and graft characteristics and compared to a healthy control group. Using the proximal anatomic axis, lateral knee radiographs were evaluated for the PTS, interrater reliability was defined, ROC curves, Fischer's exact test and Baptista-Pike method were applied to define specificity and the odds ratio for a critical PTS value. RESULTS Radiographic evaluation proved excellent interrater reliability (intraclass correlation coefficient 0.969). Evaluation of the PTS revealed 10.0 ± 2.2 (5-15) degrees in the ACL-RR group, 7.8 ± 1.8 (4.2-13) degrees in the ACL-R group and 6.6 ± 1.9 (3.6-12) degrees in the control group with significant differences between the groups (p < 0.001). A PTS value of 10.1 degrees proved a specificity of 98% for the prediction of an ACL graft failure and indicated an 11-fold risk for a retear of the ACL. CONCLUSION A PTS exceeding 10.1 degrees carries an 11-fold risk for ACL graft failure and, therefore, should be considered in ACL reconstruction. These findings might serve as a cut-off value for the indication of a slope-reducing high tibial osteotomy in ACL surgery. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Anel Dracic
- Sportsclinic Hellersen, Lüdenscheid, Germany
- Orthopädische Klinik Volmarstein, Wetter, Germany
| | | | - Ivica Zovko
- Sportsclinic Hellersen, Lüdenscheid, Germany
| | - Marcus Jäger
- Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien Hospital Mülheim, Contilia Gruppe, Mülheim, Germany
- Orthopaedics and Trauma Surgery, University of Duisburg-Essen, Essen, Germany
| | - Sascha Beck
- Sportsclinic Hellersen, Lüdenscheid, Germany
- Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien Hospital Mülheim, Contilia Gruppe, Mülheim, Germany
| |
Collapse
|
|
12
|
Tollefson LV, Rasmussen MT, Guerin G, LaPrade CM, LaPrade RF. Slope-Reducing Proximal Tibial Osteotomy Improves Outcomes in Anterior Cruciate Ligament Reconstruction Patients With Elevated Posterior Tibial Slope, Especially Revisions and Posterior Tibial Slope ≥12. Arthroscopy 2024:S0749-8063(24)00901-0. [PMID: 39536996 DOI: 10.1016/j.arthro.2024.10.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Accepted: 10/31/2024] [Indexed: 11/16/2024]
Abstract
PURPOSE To explore the indications, outcomes, and complications related to slope-reducing osteotomies in the setting of anterior cruciate ligament (ACL) tears or graft failure. A secondary aim was to create an algorithm on the basis of the current literature and authors' opinions. METHODS This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Studies were included if they reported on outcomes related to slope-reducing osteotomies both for primary ACL tears and revision ACL graft tears. The studies were analyzed to determine the radiographic outcomes, patient-reported outcomes (PROs), physical examination findings, and complications. Statistical analysis could not be performed because of the heterogeneity between studies. RESULTS A total of 148 studies were screened for inclusion in this systematic review and after full-text review, a total of 16 studies were included in this systematic review. Fourteen of the studies reported on pre- versus postoperative posterior tibial slope (PTS) and all but one reported significant decrease in PTS. Seven studies reported on pre- versus postoperative PROs, and all studies reported significant improvements in postoperative scores. Anterior tibial translation was measured in 8 studies, and all reported a significant decrease in anterior tibial translation postoperatively. The most common complication was postoperative hyperextension and irritation from hardware. Irritation from hardware was only reported in studies that used plates to fixate the osteotomy. CONCLUSIONS In conclusion, slope-reducing proximal tibial osteotomies performed concurrently or as a second-stage surgery with an anterior cruciate ligament reconstruction (ACLR) resulted in improved PROs and decreased ACLR failure rates. Slope-reducing proximal tibial osteotomies are an important treatment consideration for those patients with an increased PTS, especially for patients with a failed ACLR and a PTS ≥12°, to reduce the risk of ACLR failure. LEVEL OF EVIDENCE Level IV, systematic review of Level IV studies.
Collapse
Affiliation(s)
| | | | - Grace Guerin
- Twin Cities Orthopedics, Edina, Minnesota, U.S.A.; University of Minnesota Medical School, Minneapolis, Minnesota, U.S.A
| | | | | |
Collapse
|
|
13
|
Bohe O, Greve F, Höger S, Mehl J, Siebenlist S, Willinger L. Posteromedial corner injuries result in the same posterior translation as posterolateral corner injuries in PCL ruptures. J Exp Orthop 2024; 11:e70118. [PMID: 39697992 PMCID: PMC11653218 DOI: 10.1002/jeo2.70118] [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: 11/04/2024] [Accepted: 11/07/2024] [Indexed: 12/20/2024] Open
Abstract
Purpose Ruptures of the posterior cruciate ligament (PCL) are often accompanied by posterolateral corner (PLC) and posteromedial corner (PMC) injuries. This study investigates the incidence and impact of PMC and PLC injuries on posterior tibial translation (PTT). It was hypothesized that PMC injuries are more common and impactful than previously reported. Methods In this retrospective study, all patients with a PCL injury between January 2016 and December 2023 and received magnetic resonance imaging (MRI) within 30 days of trauma were included. Patients with atraumatic PCL instability, missing MRI or additional anterior cruciate ligament (ACL) rupture were excluded. Posttraumatic MRI was analyzed for peripheral injuries. Preoperative stress radiographs for PTT were measured, and the side-to-side difference was calculated. The statistical significance level was set at p < 0.05. Results Ninety-two patients were included, predominantly male (71.7%) with a mean age of 35.8 ± 15.6 years at injury. The mean time from injury to MRI was 7.3 ± 7.9 days. There were 16 patients (27.4%) with isolated PCL injuries. The prevalence of medial injuries (37.0% superficial medial collateral ligament [sMCL], 66.3% deep medial collateral ligament and 51.1% posterior oblique ligament [POL]) was comparable to lateral injuries (22.8% LCL, 55.4% PLC and 13.0% popliteus tendon). Injuries of the PMC (sMCL ± POL) occurred in 53 patients (57.6%) and of the PLC (POP ± PLC ± LCL) in 59 (64.1%) patients. PTT was significantly increased in the presence of a peripheral-associated injury compared to isolated PCL injury (p < 0.01). With a combined injury of PMC + PLC the PTT was significantly larger than in the case of a unilateral injury (p < 0.05 compared to PLC; p < 0.05 compared to PMC). Conclusion PCL injuries are commonly associated with PMC and/or PLC injuries. A PTT of >10 mm is equally caused by PLC and PMC-associated injuries. Knowledge about the severity and localization of peripheral-associated injuries is therefore essential for therapeutic decision-making. Level of Evidence Level III retrospective cohort study.
Collapse
Affiliation(s)
- Olivia Bohe
- Department of Sports OrthopedicsTechnical University of MunichMunichGermany
- Department of Trauma SurgeryTechnical University of MunichMunichGermany
| | - Frederik Greve
- Department of Sports OrthopedicsTechnical University of MunichMunichGermany
| | - Svenja Höger
- Department of Sports OrthopedicsTechnical University of MunichMunichGermany
| | - Julian Mehl
- Department of Sports OrthopedicsTechnical University of MunichMunichGermany
| | | | - Lukas Willinger
- Department of Sports OrthopedicsTechnical University of MunichMunichGermany
| |
Collapse
|
|
14
|
Mabrouk A, Chou A, Duouguih W, Onishi S, Mansour A, Ollivier M. Medial posterior tibial slope measurements are overestimated on long radiographs and 3D CT compared to measurements on short lateral radiographs. J Exp Orthop 2024; 11:e70120. [PMID: 39697993 PMCID: PMC11653213 DOI: 10.1002/jeo2.70120] [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: 09/09/2024] [Revised: 11/17/2024] [Accepted: 11/21/2024] [Indexed: 12/20/2024] Open
Abstract
Purpose This study assessed the measurements of the medial posterior tibial slope (MPTS) using long radiographs and three-dimensional (3D) computed tomography (CT) scans and compared them to measurements taken on short lateral knee radiographs. The study aimed to identify whether the at-risk slope measurements previously defined on the short radiographs would be similar to long radiographs and 3D CT scans. Methods A retrospective radiological review of 52 cases, who underwent planning for a slope-changing high tibial osteotomy and had short and long lateral radiographs and 3D CT scans of the tibia. Two independent observers measured the MPTS on the three modalities. The MPTS was defined as the angle between a tangent to the medial tibial plateau and the referenced tibia anatomical axis. The MPTS measurements from the short and long radiographs were compared to each other and then were compared to the measurements performed on the CT scan. False positives were defined as those cases with MPTS measurements of >78° on CT scans or long radiographs while having measurements ≤78° on short radiographs. These false positive cases are the ones which would be falsely labelled as having an abnormal slope based on the previously validated short radiograph slope threshold ≥12°. Results A total of 52 cases were analysed (67.9% males and 32.1% females). The mean age was 27 ± 5.4 years. The mean weight was 71.5 ± 7.7 kg, and the mean height was 1.8 ± 0.1 m. The mean MPTS measured on the short radiographs was 77.3 ± 2.3°; on the long radiographs, it was 75.8 ± 2.0°; and on the CT scan, it was 75.3 ± 2.1°. There was a positive correlation between the measurements taken on both the short and long radiographs (r = 0.9) (p < 0.001). Additionally, there was a positive correlation between CT tibial slope measurements and both short and long radiographs tibial slope measurements (r = 0.86, r = 0.87), respectively (both p < 0.001). False positives were 13 (25%) patients on long radiographs, and 12 (23.1%) patients on CT scans, who had their MPTS measurements ≤78° (equivalent of PTS ≥ 12°) while their measurements were >78° on the short radiographs. Conclusion Measurements of the MPTS can be overestimated by 1.5-2° on long lateral knee radiographs or 3D CT scans compared to measurements taken on short lateral radiographs. Different thresholds for the abnormal PTS measurements on long radiographs and CT scans, should be defined, considering the overestimated measurements in these modalities. Level of Evidence Level IV case series.
Collapse
Affiliation(s)
- Ahmed Mabrouk
- Department of Trauma & OrthopaedicsBasingstoke and North Hampshire HospitalBasingstokeUK
- Department of Orthopaedics and Traumatology, Aix Marseille Univ, APHM, CNRS, ISM, Sainte‐Marguerite HospitalInstitute for LocomotionMarseilleFrance
| | - Arthur Chou
- Department of Orthopaedic SurgeryThe Union Memorial HospitalBaltimoreMarylandUSA
| | - Wiemi Duouguih
- Department of Orthopaedic SurgeryThe Union Memorial HospitalBaltimoreMarylandUSA
| | - Shintaro Onishi
- Department of Orthopaedics and Traumatology, Aix Marseille Univ, APHM, CNRS, ISM, Sainte‐Marguerite HospitalInstitute for LocomotionMarseilleFrance
| | - Alfred Mansour
- Department of Orthopedic Surgery, McGovern Medical SchoolUniversity of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Matthieu Ollivier
- Department of Orthopaedics and Traumatology, Aix Marseille Univ, APHM, CNRS, ISM, Sainte‐Marguerite HospitalInstitute for LocomotionMarseilleFrance
| |
Collapse
|
|
15
|
Peez C, Waider C, Deichsel A, Briese T, Palma Kries LK, Herbst E, Raschke MJ, Kittl C. Proximal tibial anatomical axis and anterior tibial cortex-based measurements of posterior tibial slope on lateral radiographs differ least from actual posterior tibial slope-A biomechanical study. J Exp Orthop 2024; 11:e70108. [PMID: 39664925 PMCID: PMC11632255 DOI: 10.1002/jeo2.70108] [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: 09/13/2024] [Revised: 10/16/2024] [Accepted: 10/19/2024] [Indexed: 12/13/2024] Open
Abstract
Purpose To compare different measurement techniques of the posterior tibial slope (PTS) on lateral radiographs with the actual in situ PTS and evaluate the effect of tibial malrotation and image section length. Methods Actual PTS was measured on eight fresh-frozen tibiae using a portable 6-axis measuring arm with an accuracy of ±0.01°. True lateral radiographs were taken in the neutral position and after applying 10/20/30° internal/external rotation (IR/ER) and 5/10/15° varus/valgus rotation. The PTS was measured radiographically using five different reference axes: anterior tibial cortex (ATC), anatomical tibial axis, proximal tibial anatomical axis (PTAA), posterior tibial cortex (PTC) and fibular shaft axis (FSA). Results The ATC and PTAA methods showed the lowest deviation from the actual PTS, while the PTC method showed the highest difference of 5.5 ± 1.5° (medial) and 7.1 ± 1.8° (lateral) among all tested methods (p < .001). The PTAA technique showed a 1.9 ± 1.4° (medial) and 2.9 ± 1.8° (lateral) difference from the actual slope (n.s.). ER caused the PTS to increase 0.7 ± 2.0° (10° ER, n.s.) to 3.4 ± 2.1° (30° ER, p < .05), whereas IR caused the PTS to decrease 1.6 ± 1.3° (n.s) to 4.1 ± 1.7° (p < .05) when comparing to the PTAA method for the neutral position. Varus and valgus rotation showed the highest deviation from the neutral rotation at 15° valgus (3.1 ± 2.1°, n.s.). Conclusion Tibial slope measurements have a high degree of variability between different measurement methods, while the ATC and PTAA methods showed the least deviation from the actual PTS measured in this in vitro model. Malrotation resulted in a severe distortion of the PTS values, which may alter preoperative planning and intraoperative results. Therefore, radiographic PTS measurements may be contrasted with more objective, reproducible and reliable measuring methods. Level of Evidence There is no level of evidence as this study was an experimental laboratory study.
Collapse
Affiliation(s)
- Christian Peez
- Department of Trauma, Hand and Reconstructive SurgeryUniversity Hospital MünsterMünsterGermany
| | - Caroline Waider
- Department of Trauma, Hand and Reconstructive SurgeryUniversity Hospital MünsterMünsterGermany
| | - Adrian Deichsel
- Department of Trauma, Hand and Reconstructive SurgeryUniversity Hospital MünsterMünsterGermany
| | - Thorben Briese
- Department of Trauma, Hand and Reconstructive SurgeryUniversity Hospital MünsterMünsterGermany
| | - Lucas K. Palma Kries
- Department of Trauma, Hand and Reconstructive SurgeryUniversity Hospital MünsterMünsterGermany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive SurgeryUniversity Hospital MünsterMünsterGermany
| | - Michael J. Raschke
- Department of Trauma, Hand and Reconstructive SurgeryUniversity Hospital MünsterMünsterGermany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive SurgeryUniversity Hospital MünsterMünsterGermany
| |
Collapse
|
|
16
|
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.
Collapse
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
| |
Collapse
|
|
17
|
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.
Collapse
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..
| |
Collapse
|
|
18
|
Garra S, Li ZI, Triana J, Savage-Elliott I, Moore MR, Kanakamedala A, Campbell K, Alaia M, Strauss EJ, Jazrawi LM. The influence of tibial length on radiographic posterior tibial slope measurement: How much tibia do we need? Knee 2024; 49:167-175. [PMID: 38981280 DOI: 10.1016/j.knee.2024.06.005] [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: 02/14/2024] [Revised: 04/24/2024] [Accepted: 06/11/2024] [Indexed: 07/11/2024]
Abstract
PURPOSE The purpose of this study was to determine whether significant differences exist when comparing posterior tibial slope (PTS) measured using increasing lengths of the tibia to determine the anatomical axis. METHODS Patients with full-length weight-bearing tibial radiographs were retrospectively identified from 2014 to 2022 at a single institution. Patients were excluded if there was any previous history of lower extremity fracture or osteotomy. The anatomical axis of the tibia was determined using the full length of tibial radiographs, and the "reference PTS" was measured using this axis. Using the same radiograph, the PTS was measured using four different anatomical axes at standardized tibial lengths. While the center of the proximal circle remained constant at 5-cm below the tibial plateau, the center of the distal circle was drawn at four points: a) overlapping circles; b) 10-cm distal to the tibial plateau; c) 15-cm distal to the tibial plateau; d) half the length of the tibia, measured from the tibial plateau to the tibial plafond. Bivariate correlation and frequency distribution analysis (measurements >2-degrees from reference PTS) were performed between the reference PTS and PTS measured at each of the four other lengths. RESULTS A total of 154 patients (39.8 ± 17.4 years old, 44.2% male) were included in the final analysis. Measurements at each of the four tibial lengths were all significantly different from the reference PTS (p < 0.001). The correlation strength improved with increasing tibial length (overlapping: R = 0.681, 10-cm: R = 0.821, 15-cm: R = 0.937, and half-tibia: R = 0.963). The number of PTS measurements >2-degree absolute difference from the reference PTS decreased with increasing tibial length (overlapping: 40.3%, 10-cm: 24.0%, 15-cm: 26.0%, and half-tibia: 18.8%). CONCLUSION Assessment of PTS is dependent on the length of the tibia utilized to obtain the anatomical axis. Accuracy and precision of PTS measurements improved with increasing length of tibia used to determine the anatomical axis. STUDY DESIGN Case series.
Collapse
|
|
19
|
Cacciola G, Giustra F, Bosco F, Vezza D, Pirato F, Braconi L, Risitano S, Capella M, Massè A, Sabatini L. No significant clinical differences between native or reduced posterior tibial slope in kinematically aligned total knee replacement with posterior cruciate-retaining. J Orthop 2024; 54:32-37. [PMID: 38524363 PMCID: PMC10957378 DOI: 10.1016/j.jor.2024.03.023] [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: 03/10/2024] [Accepted: 03/13/2024] [Indexed: 03/26/2024] Open
Abstract
Aims & objectives Total knee arthroplasty (TKA) is a common surgical procedure for end-stage knee osteoarthritis. However, conventional alignment techniques may lead to postoperative dissatisfaction in up to 20% of cases. Kinematic alignment (KA) has emerged as a new philosophy to restore the native joint line and achieve more natural kinematics. Preserving the posterior tibial slope (PTS) and posterior cruciate ligament (PCL) is crucial to maintaining the pre-arthritic joint line and improving knee kinematics. This study aimed to assess the prevalence of postoperative PTS changes and their impact on functional outcomes and range of motion. Materials & methods A retrospective single-center study was conducted on patients who underwent KA-TKA with PCL preservation. The preoperative and postoperative PTS were measured on lateral knee radiographs using the tibial proximal anatomic axis method. Patient-reported outcome measures (PROMs) were collected pre- and postoperatively up to a two-year follow-up. Results Of the 95 included patients, 62.1% achieved an anatomically similar PTS (within 3° from the preoperative value), while 37.9% experienced noticeable PTS changes. However, no significant associations existed between PTS changes and compromised PROMs (WOMAC, 22.2 and 23.1; FJS, 66.6 and 67.3), ROM (118.5° and 119.4°), or patient satisfaction. No postoperative complications requiring reoperation or component revisions were observed. Conclusion Preserving or modifying the native PTS during KA-TKA could be confidently undertaken without compromising functional outcomes or patient satisfaction.
Collapse
Affiliation(s)
- Giorgio Cacciola
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Torino, Italy
| | - Fortunato Giustra
- Department of Orthopaedics and Traumatology, San Giovanni Bosco Hospital—ASL Città di Torino, 10154, Turin, Italy
| | - Francesco Bosco
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy
- Department of Orthopaedics and Traumatology, G.F. Ingrassia Hospital Unit, ASP 6, Palermo, Italy
| | - Daniele Vezza
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Torino, Italy
| | - Francesco Pirato
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Torino, Italy
| | - Lorenzo Braconi
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Torino, Italy
| | - Salvatore Risitano
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Torino, Italy
| | - Marcello Capella
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Torino, Italy
| | - Alessandro Massè
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Torino, Italy
| | - Luigi Sabatini
- Humanitas Gradenigo, Department of Robotic and Minimally-Invasive Arthroplasty Surgery, 10153, Turin, Italy
| |
Collapse
|
|
20
|
Olson CP, Mabrouk A, Liechti DJ, Tollefson LV, Kennedy NI, LaPrade RF. Inconsistent Return to Sport Despite Improved Outcomes After Re-revision Anterior Cruciate Ligament Reconstruction: An Updated Systematic Review. Arthroscopy 2024; 40:2096-2111. [PMID: 38092276 DOI: 10.1016/j.arthro.2023.12.001] [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] [Received: 09/10/2023] [Revised: 11/25/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE To systematically review the literature evaluating patient-reported outcomes and return to sport after re-revision anterior cruciate ligament reconstruction (ACLR) procedures. The secondary objectives were 2-fold: to identify the risk factors that lead to revision ACLR failure and to assess the secondary knee structure injuries after the initial revision ACLR. METHODS A systematic review of the literature was performed using the MEDLINE/PubMed and Cochrane databases. The inclusion criteria were outcomes of re-revision ACLR, minimum of 2 years' follow-up, human studies, and English language. Basic science articles, epidemiologic studies, editorials, surgical technique articles, surveys, cadaveric studies, and animal studies were excluded. RESULTS Fifteen studies met the inclusion criteria and were considered for review. There were 6 Level III and 9 Level IV studies that included 399 patients undergoing re-revision ACLR. The rate of concomitant meniscal lesions at the time of re-revision ranged from 35% to 90%. The prevalence of concomitant cartilaginous lesions at the time of re-revision ranged from 13.6% to 90%. Compared with preoperative scores, patient-reported outcomes overall improved after re-revision ACLR, with mean preoperative Lysholm scores ranging from 38.4 to 73.15 that improved to postoperative scores ranging from 68 to 87.8. However, return to sport at preinjury levels was inconsistent, with rates ranging from 12.5% to 80%. CONCLUSIONS Re-revision ACLR was found to restore knee stability and improve functional outcomes. Despite this improvement, there was a low rate of return to sport at the preinjury level. Functional outcomes were also inferior when compared with primary ACLR. In addition, concomitant knee pathologies were found to rise in prevalence compared with revision and primary ACLR cases. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies.
Collapse
Affiliation(s)
- Conner P Olson
- University of Minnesota Medical School, Minneapolis, Minnesota, U.S.A
| | - Ahmed Mabrouk
- Mid Yorkshire Teaching Hospitals, Yorkshire, England, United Kingdom
| | - Daniel J Liechti
- Black Hills Orthopedic & Spine Center of Wyoming, Gillette, Wyoming, U.S.A
| | | | | | | |
Collapse
|
|
21
|
Tylla AHR, Tylla D, Lahm M, Mauerer J, Stangl R, Doro A. [The correct tibial slope? Comparison of measuring methods]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:527-540. [PMID: 38884651 DOI: 10.1007/s00132-024-04521-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 06/18/2024]
Abstract
INTRODUCTION From a biomechanical point of view, the tibial slope plays a significant role in relation to the loading of the ligament structures in the knee joint. Currently, there are various methods of measurement for the tibial slope, which makes it difficult to compare the measurement results obtained. These differences can be decisive factors for the indication and the extent respectively of the correction of the tibial slope. The aim of this work is to present the differences in results between the measurement methods, and to compare these with the posterior tibial slope (PTS). METHODS By means of a comparative analysis, six measurement techniques for the tibial slope were examined. Using six parameters (correlation coefficient, range, deviation of the average slope value, correction coefficient, difference in the corrected measurements, range of the corrected measurements), these results were compared with the PTS. In this prospective study, the PTS was measured in 107 (49 male, 58 female, age 42.6 ± 23.4 years) strictly lateral plain radiological projections of the tibia with the talocrural joint in comparison with the measurement methods according to Han, Brazier, Moore and Harvey, Pietrini and LaPrade and a supratuberosity measurement. RESULTS The posterior slope was observed at a mean value of 6.9° (± 8.6°). Compared with the PTS, tibial slope values were increased in 55.5 % of all measurements examined and decreased in 42.4 %. In 2 % the values were identical to those of PTS. The deviations observed were significant at up to +2.9° (± 1.7°) and -2.3° (± 1.5°) respectively in comparison with the measured PTS (p < 0.001). 25.9 % of the results showed a slope value more than 2°too high and 17.6 % one less than -2° too low. Thus, in 43 % of the results clinically relevant results that were too high or too low were observed for the tibial slope compared with the PTS (p < 0.001). The correlation analyses showed very high linear connections with PTS (p < 0.001) for all methods, from r2 = 0.88 (in Moore and Harvey) up to r2 = 0.98 (in Han). The ranges varied between 13.90° (Moore and Harvey) and 18.30° (Han). CONCLUSION Depending on the measurement method, the slope values obtained should be individually evaluated, in order to draw the correct clinical conclusions. In principle, the radiological assessment of the whole lower leg is essential, so that concomitant pathologies in the area of the entire tibia can be detected. In everyday clinical practice, the measurement according to Han et al., and thus a shorter X‑ray projection, makes it possible to draw optimal conclusions about the PTS. LOE: Prospective diagnostic study, Level II.
Collapse
Affiliation(s)
- Alfred H R Tylla
- Hospital Rummelsberg gGmbH: Krankenhaus Rummelsberg gGmbH, Schwarzenbruck, Deutschland.
| | | | - Moritz Lahm
- Hospital Rummelsberg gGmbH: Krankenhaus Rummelsberg gGmbH, Schwarzenbruck, Deutschland
| | - Josef Mauerer
- Hospital Rummelsberg gGmbH: Krankenhaus Rummelsberg gGmbH, Schwarzenbruck, Deutschland
| | - Richard Stangl
- Hospital Rummelsberg gGmbH: Krankenhaus Rummelsberg gGmbH, Schwarzenbruck, Deutschland
| | - Anton Doro
- Hospital Rummelsberg gGmbH: Krankenhaus Rummelsberg gGmbH, Schwarzenbruck, Deutschland
| |
Collapse
|
|
22
|
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.
Collapse
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
| |
Collapse
|
|
23
|
Narahashi É, Guimarães JB, Filho AGO, Nico MAC, Silva FD. Measurement of tibial slope using biplanar stereoradiography (EOS®). Skeletal Radiol 2024; 53:1091-1101. [PMID: 38051424 DOI: 10.1007/s00256-023-04528-9] [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: 10/02/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/07/2023]
Abstract
OBJECTIVES Posterior tibial slope (PTS) is an important anatomic parameter of the knee related to anteroposterior instability. Biplanar stereoradiography allows for simultaneous low-dose acquisition of anteroposterior and lateral views with 3D capability, enabling separate lateral and medial plateau analyses. We aimed to evaluate the possibility and compare the reproducibility of measuring medial and lateral PTS on EOS® images with two different patient positionings and compare it with CT of the knees as the gold standard. METHODS This is a retrospective study including volunteers who underwent lower limb stereoradiography and knee CT from 01/08/2016 to 07/31/2019. Sixty legs from 30 patients were studied. PTS were measured using stereoradiography and CT by two radiologists. Intraclass correlation was used to calculate intrarater and interrater reproducibilities. Pearson's correlation coefficients were used to calculate the correlation between stereoradiography and CT. We also compared the reproducibility of the stereoradiography of volunteers with 2 different positionings. RESULTS The mean stereoradiography PTS values for right and left knees were as follows: lateral, 12.2° (SD: 4.1) and 10.1° (SD: 3.5); medial,12.2° (SD: 4.4) and 11.6° (SD: 3.9). CT PTS mean values for right and left knee are as follows: lateral, 10.3° (SD:2.5) and 10.6° (SD: 2.8); medial: 8.7° (SD: 3.7) and 10.4° (SD: 3.5). Agreement between CT and EOS for angles between lateral and medial PTS was good (right, 0.874; left, 0.871). Regarding patient positioning on stereoradiography, interrater and intrarater reproducibilities were greater for patients with nonparallel feet (0.738-0.883 and 0.870-0.975). CONCLUSIONS Stereoradiography allows for appropriate delineation of tibial plateaus, especially in patients with nonparallel feet, for the purpose of measuring PTS. The main advantage is lower radiation doses compared to radiography and CT.
Collapse
Affiliation(s)
- Érica Narahashi
- Department of Musculoskeletal Radiology, Fleury Medicine and Health, Rua Mato Grosso, 306, 1o andar, Higienópolis, São Paulo, São Paulo, 01239-040, Brazil.
| | - Júlio Brandão Guimarães
- Department of Musculoskeletal Radiology, Fleury Medicine and Health, Rua Mato Grosso, 306, 1o andar, Higienópolis, São Paulo, São Paulo, 01239-040, Brazil
| | - Alípio Gomes Ormond Filho
- Department of Musculoskeletal Radiology, Fleury Medicine and Health, Rua Mato Grosso, 306, 1o andar, Higienópolis, São Paulo, São Paulo, 01239-040, Brazil
| | - Marcelo Astolfi Caetano Nico
- Department of Musculoskeletal Radiology, Fleury Medicine and Health, Rua Mato Grosso, 306, 1o andar, Higienópolis, São Paulo, São Paulo, 01239-040, Brazil
| | - Flávio Duarte Silva
- Department of Musculoskeletal Radiology, Fleury Medicine and Health, Rua Mato Grosso, 306, 1o andar, Higienópolis, São Paulo, São Paulo, 01239-040, Brazil
| |
Collapse
|
|
24
|
Bouché PA, Fayard JM. Resurgence of slope osteotomies: A new chapter in anterior cruciate ligament surgery? Orthop Traumatol Surg Res 2024; 110:103902. [PMID: 38723746 DOI: 10.1016/j.otsr.2024.103902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 05/03/2024] [Indexed: 05/20/2024]
Affiliation(s)
- Pierre-Alban Bouché
- Service de chirurgie orthopédique et traumatologique, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France.
| | - Jean-Marie Fayard
- Ramsay Santé, hôpital privé Jean-Mermoz, centre orthopédique Santy, FIFA Medical Center of Excellence, 24, avenue Paul-Santy, 69008 Lyon, France
| |
Collapse
|
|
25
|
Dobrich J, Bauer S, Elicegui S, LaCour M, Ries M. Effect of Posterior Tibial Slope on Knee Kinematics After Bicruciate-Retaining Total Knee Arthroplasty. Arthroplast Today 2024; 27:101417. [PMID: 38882467 PMCID: PMC11180305 DOI: 10.1016/j.artd.2024.101417] [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: 09/25/2023] [Revised: 02/25/2024] [Accepted: 04/28/2024] [Indexed: 06/18/2024] Open
Abstract
Background Following total knee arthroplasty (TKA), normal knee kinematics are rarely replicated. Retention of both cruciate ligaments (bicruciate retaining TKA) has helped this. Postoperative posterior tibial slope (PPTS) may further affect ligament tension and kinematics. The objective of this study is to determine how changes between the preoperative posterior tibial slope (PTS) and PPTS affect knee kinematics. Methods Twenty bicruciate retaining TKAs were performed using standard instrumentation. Fluoroscopic kinematic data were obtained during gait and a single knee bend. Differences (Δ) between radiographic measurements of preoperative and PPTS were correlated with in-vivo knee kinematics. Patients were separated into 2 groups based on their Δ values. Group I consisted of Δ values less than 0.7, indicating either a similar PPTS compared to preoperative PTS or a slightly flatter PPTS. Group II consisted of Δ values above 0.7, indicating a steepened PPTS. Results Preoperative PTS values ranged from -0.5° to 11.2°, with an average of 5.0° ± 3.4°. PPTS values ranged from 3.0° to 12.1°, with an average of 7.1° ± 3.1°. Weight-bearing range of motion (WBROM) measured from 94° to 139°, and femorotibial axial rotation ranged from -2.9° to 17.3°. A t-test revealed average values for WBROM in Group IT (Δ < 0.7) to be significantly greater than those for Group IIT (Δ > 0.7) (P = .01). Conclusions These findings indicate that either a PPTS approximating the preoperative PTS or a slightly flattened PPTS in comparison (Δ < 0.7) is associated with WBROM greater than 130°. Values for axial rotation and anterior sliding were not significantly associated with changes to the PTS.
Collapse
|
|
26
|
Conyer RT, Wang AS, Langhans MT, Krych AJ, Hevesi M, Okoroha KR, Stuart MJ, Levy BA. Association of Posterior Tibial Slope With Outcomes After Multiligamentous Knee Reconstruction for Knee Dislocation Grades 2 to 4. Orthop J Sports Med 2024; 12:23259671241249473. [PMID: 38757069 PMCID: PMC11097713 DOI: 10.1177/23259671241249473] [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: 10/31/2023] [Accepted: 11/16/2023] [Indexed: 05/18/2024] Open
Abstract
Background Patients with isolated anterior cruciate ligament (ACL) reconstruction have demonstrated an increased risk of ACL graft failure and lower patient-reported outcome (PRO) scores when increased posterior tibial slope (PTS) is present. However, there is a paucity of literature evaluating the effect of PTS on outcomes after combined bicruciate multiligamentous knee reconstruction. Purpose To determine whether differences exist for graft failure rates or PRO scores based on PTS after combined bicruciate multiligamentous knee reconstruction. Study Design Cohort study; Level of evidence, 3. Methods All patients who underwent combined ACL and posterior cruciate ligament (PCL) reconstruction between 2000 and 2020 at our institution were identified. Exclusion criteria were age <18 years, knee dislocation grade 5 injuries, concomitant osteotomy procedures, and <2 years of clinical follow-up. Demographic and outcomes data were collected from our prospectively gathered multiligamentous knee injury database. Lysholm and International Knee Documentation Committee (IKDC) scores were analyzed in relation to PTS. Outcomes were compared for patients with a PTS above and below the mean for the total cohort, PTS >12° versus <12°, positive versus negative Lachman test at follow-up, and positive versus negative posterior drawer test at follow-up. Results A total of 98 knees in 98 patients were included in the study, with a mean clinical follow-up of 5.1 years (median, 4.6 years; range, 2-16 years). The mean PTS was 8.7° (range, 0.4°-16.9°). Linear regression analysis showed no significant correlation between PTS and IKDC or Lysholm scores. Patients with a PTS above the mean of 8.7° trended toward lower IKDC (P = .08) and Lysholm (P = .06) scores. Four patients experienced ACL graft failure and 5 patients experienced PCL graft failure. There were no differences in graft failure rates or PRO scores for patients with a PTS >12°. Patients with a positive Lachman test trended toward higher PTS (9.6° vs 8.5°, P = .15). Conclusion In this series of bicruciate multiligamentous knee reconstructions at midterm follow-up, no differences in graft failures, complications, reoperations, revisions, or PRO scores based on PTS were identified. Patients with a positive Lachman test were found to have a slightly higher PTS, although this did not reach statistical significance.
Collapse
Affiliation(s)
- Ryan T. Conyer
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Allen S. Wang
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark T. Langhans
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J. Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mario Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelechi R. Okoroha
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J. Stuart
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bruce A. Levy
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
|
27
|
Veerman QW, ten Heggeler RM, Tuijthof GJ, de Graaff F, Fluit R, Hoogeslag RA. Three-Dimensional Hinge Axis Orientation Contributes to Simultaneous Alignment Correction in All Three Anatomical Planes in Opening-Wedge High Tibial Osteotomy. Arthrosc Sports Med Rehabil 2024; 6:100888. [PMID: 38356465 PMCID: PMC10864846 DOI: 10.1016/j.asmr.2024.100888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/02/2024] [Indexed: 02/16/2024] Open
Abstract
Purpose To investigate the simultaneous effect of 3-dimensional (3D) hinge axis (HA) orientation on alignment parameters in all 3 anatomical planes in high tibial osteotomy. Methods A computed tomography-based 3D model of a human tibia/fibula was used to establish a 3D tibial coordinate system based on the tibial mechanical axis. In here, an HA was positioned and an opening-wedge high tibial osteotomy with a rotation angle of 10° over the HA was simulated. HA rotation in the axial plane ranged from 0° to 90° and HA tilt relative to the axial plane ranged from -20° to +20°. The study quantified the simultaneous effect of HA orientation on change of alignment parameters in all anatomical reference planes. Results HA rotation within the tibial axial plane between orientations perpendicular to the coronal and sagittal planes primarily affected both coronal and sagittal plane alignment, with an inverse relationship between these planes (range: 0°-9.7°); the effect of HA rotation on the change in axial plane alignment was maximally 0.9°. In contrast, HA tilt relative to the tibial axial plane primarily affected axial alignment (maximum change: 6.9°); the effect on change in both coronal and sagittal plane alignment was maximally 0.6°. Conclusions HA rotation in the tibial axial plane primarily affects sagittal and coronal plane alignment, and HA tilt relative to the tibial axial plane primarily affects axial plane alignment. Clinical Relevance Integrating 3D HA orientation in malalignment planning and correction offers the potential to minimize unintended corrections in nontargeted planes in uniplanar correction osteotomies and to facilitate intentional multiplanar correction with a single osteotomy.
Collapse
Affiliation(s)
- Quinten W.T. Veerman
- OCON Centre for Orthopaedic Surgery and Sports Medicine, Hengelo, the Netherlands
- Faculty of Engineering Technology, University of Twente, Enschede, the Netherlands
| | - Romy M. ten Heggeler
- OCON Centre for Orthopaedic Surgery and Sports Medicine, Hengelo, the Netherlands
- Faculty of Engineering Technology, University of Twente, Enschede, the Netherlands
| | | | - Feike de Graaff
- OCON Centre for Orthopaedic Surgery and Sports Medicine, Hengelo, the Netherlands
| | - René Fluit
- Faculty of Science and Engineering, University of Groningen, Groningen, the Netherlands
| | - Roy A.G. Hoogeslag
- OCON Centre for Orthopaedic Surgery and Sports Medicine, Hengelo, the Netherlands
| |
Collapse
|
|
28
|
Ueda Y, Matsushita T, Shibata Y, Takiguchi K, Ono K, Kida A, Nishida K, Nagai K, Hoshino Y, Matsumoto T, Sakai Y, Kuroda R. Association Between Psychological Readiness to Return to Sports at 3 Months Postoperatively and Risk of Second ACL Injury. Orthop J Sports Med 2024; 12:23259671241239325. [PMID: 38584989 PMCID: PMC10996360 DOI: 10.1177/23259671241239325] [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: 12/03/2023] [Accepted: 01/10/2024] [Indexed: 04/09/2024] Open
Abstract
Background Psychological readiness to return to sports (RTS) has been associated with second anterior cruciate ligament (ACL) injury. However, this relationship is controversial because covariates such as anatomic and knee function characteristics have not been adequately considered. Purpose/Hypothesis To investigate whether psychological readiness in the early postoperative period can predict the occurrence of a second ACL injury within 24 months after primary ACL reconstruction (ACLR) using propensity score analysis. It was hypothesized that patients with high ACL-RSI after injury (ACL-RSI) scores at 3 months postoperatively would have a second ACL injury within the projected postoperative period. Study Design Cohort study; Level of evidence, 3. Methods Included were 169 patients who underwent primary ACLR using hamstring tendon autografts between November 2017 and July 2021 and also underwent knee functional assessments at 3 months postoperatively. The ACL-RSI scale was used to assess psychological readiness for RTS. A second ACL injury was defined if ipsilateral or contralateral ACL injury was confirmed by examination within 24 months postoperatively. Based on a previous study showing that 65 was the highest cutoff value for the ACL-RSI score for RTS, we classified patients into 2 groups: those with high ACL-RSI scores (≥65; group H) and those with low ACL-RSI scores (<65; group L). We generated 1-to-1 matched pairs using propensity score analysis and used log-rank testing to compare the rate of second ACL injury between the 2 groups. Results More patients returned to any sports activities within 12 months in group H than in group L (90% vs 73%; P = .03). A second ACL injury within 24 months postoperatively was identified in 7% of patients (13/169). The rate of second ACL injury was significantly higher in group H than in group L (17.6% vs 3.4%; P = .001). In 43 matched pairs extracted using propensity scoring, the rate of second ACL injury was also higher in group H than in group L (18.6% vs 4.7%; P = .04). Conclusion Patients with a higher ACL-RSI score at 3 months exhibited a significantly higher incidence of second ACL injury within 24 months after primary ACLR.
Collapse
Affiliation(s)
- Yuya Ueda
- Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yohei Shibata
- Division of Rehabilitation Medicine, Kobe University Hospital, Kobe, Japan
| | - Kohei Takiguchi
- Division of Rehabilitation Medicine, Kobe University Hospital, Kobe, Japan
| | - Kumiko Ono
- Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Akihiro Kida
- Division of Rehabilitation Medicine, Kobe University Hospital, Kobe, Japan
| | - Kyohei Nishida
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshitada Sakai
- Division of Rehabilitation Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| |
Collapse
|
|
29
|
Goto K, Hirota J, Miyamoto Y, Katsuragawa Y. The Accuracy of a Portable Accelerometer-Based Navigation System for Tibial Alignment Can be Reliable during Total Knee Arthroplasty for Obese Patients. J Knee Surg 2024; 37:303-309. [PMID: 37192656 DOI: 10.1055/a-2094-8822] [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: 05/18/2023]
Abstract
A portable accelerometer-based navigation system can be useful for achieving the target alignment. Tibial registration is based on the medial and lateral malleoli; however, the identification of landmarks may be difficult in obese (body mass index [BMI] >30 kg/m2) patients whose bones are not easily palpable from the body surface. This study compared tibial component alignment achieved using a portable accelerometer-based navigation system (Knee Align 2 [KA2]) in obese and control groups and aimed to validate the accuracy of bone cutting in obese patients. A total of 210 knees that underwent primary total knee arthroplasty using the KA2 system were included. After 1:3 propensity score matching, there were 32 and 96 knees in the BMI >30 group (group O) and BMI ≤30 group (group C), respectively. The absolute deviations of the tibial implant from the intended alignment were evaluated in the coronal plane (hip-knee-ankle [HKA] angle and medial proximal tibial angle) and sagittal plane (posterior tibial slope [PTS]). The inlier rate of each cohort, which was defined as tibial component alignment within 2 degrees of the intended alignment, was investigated. In the coronal plane, the absolute deviations of the HKA and MPTA from the intended alignment were 2.2 ± 1.8 degrees and 1.8 ± 1.5 degrees in group C and 1.7 ± 1.5 degrees and 1.7 ± 1.0 degrees in group O (p = 1.26, and p = 0.532). In the sagittal plane, the absolute deviations of the tibial implant were 1.6 ± 1.2 degrees in group C and 1.5 ± 1.1 degrees in group O (p = 0.570). The inlier rate was not significantly different between group C and group O (HKA: 64.6 vs. 71.9%, p = 0.521; MPTA: 67.7 vs. 78.1%, p = 0.372; PTS: 82.2 vs. 77.8%, p = 0.667). The accuracy of tibial bone cutting for the obese group was comparable to that of the control group. An accelerometer-based portable navigation system can be useful when attempting to achieve the target tibial alignment in obese patients. LEVEL OF EVIDENCE: Level IV.
Collapse
Affiliation(s)
- Kazumi Goto
- Department of Orthopaedic Surgery, Mitsui Memorial Hospital, Chiyoda-ku, Tokyo, Japan
| | - Jinso Hirota
- Department of Orthopaedic Surgery, Mitsui Memorial Hospital, Chiyoda-ku, Tokyo, Japan
| | - Yoshinari Miyamoto
- Department of Orthopaedic Surgery, Center Hospital of the National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yozo Katsuragawa
- Department of Orthopaedic Surgery, Mitsui Memorial Hospital, Chiyoda-ku, Tokyo, Japan
| |
Collapse
|
|
30
|
Guy S, Saithna A, Ferreira A, Carrozzo A, Vieira TD, Ollivier MP, Sonnery-Cottet B. The Influence of Tibial Tubercle-Sparing Slope-Reducing Osteotomy on Patellar Height in Patients Undergoing Revision ACL Reconstruction. Am J Sports Med 2024; 52:919-927. [PMID: 38385201 DOI: 10.1177/03635465241228264] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND A posterior tibial slope (PTS) >12° is an independent risk factor for anterior cruciate ligament (ACL) graft rupture, and a high tibial osteotomy (HTO) for slope correction can help avoid it. Management of patellar height is of major concern when performing HTO. PURPOSE To evaluate the effect of tibial tubercle-sparing anterior closing-wedge osteotomy on patellar height in revision ACL reconstruction (ACLR). STUDY DESIGN Case series; Level of evidence, 4. METHODS Patients who underwent arthroscopic revision ACLR combined with retro-tibial tubercle anterior closing-wedge HTO (ACW-HTO) between January 1, 2016, and March 31, 2021, were assessed for eligibility. Patellar height was measured on full weightbearing lateral radiographs according to the Insall-Salvati index (ISI) and Caton-Deschamps index (CDI) or frontal radiographs using the femoral patellar height index. The PTS was evaluated using the proximal anatomic axis of the tibia on standard short lateral radiographs. The delta (postoperative - preoperative) and the ratio (preoperative/postoperative) of the 3 patellar height indices and PTS were calculated. Preoperative and postoperative patellar heights were compared using independent t tests for each index. Also investigated was whether patients changed patellar height category (baja, normal, or alta) after slope osteotomy. RESULTS Among 475 revision ACLRs, 47 tibial tubercle-sparing ACW-HTOs were retained for analysis. No significant difference in patellar height was found between pre- and postoperative radiographs regardless of the index (preoperative - postoperative) (ISI: 1.0 ± 0.2 - 0.9 ± 0.2, P = .1729; CDI: 1.0 ± 0.2 - 1.0 ± 0.2, P = .4034; femoral patellar height index: 1.5 ± 0.2 - 1.5 ± 0.2; P = .5130). Fifteen patients (31.9%) exhibited a postoperative change in their patellar height category when measured by the ISI (6 moved up a category, 9 moved down one), and 18 patients (38.3%) changed category according to the CDI (10 moved up a category, 8 moved down one). No significant difference was found between pre- and postoperative patellar height among these patients (ISI: P = .2418; CDI: P = .3005). CONCLUSION Changes in patellar height ratio are common after tibial tubercle-sparing ACW-HTO in patients undergoing revision ACLR. The clinical effect of these changes is unknown, and further study is needed to investigate whether they may result in patellofemoral symptoms.
Collapse
Affiliation(s)
- Sylvain Guy
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Adnan Saithna
- AZBSC Orthopedics, Scottsdale, Arizona, USA
- Arizona State University, Tempe, Arizona, USA
| | - Alexandre Ferreira
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Alessandro Carrozzo
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Matthieu P Ollivier
- Institute of Movement and Locomotion, Department of Orthopedics and Traumatology, St. Marguerite Hospital, Marseille, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| |
Collapse
|
|
31
|
Kavak S, Kaya S. Evaluation of the relationship of posterior tibial slope with gender and age in Turkish population with 3 different methods. BMC Musculoskelet Disord 2024; 25:102. [PMID: 38291387 PMCID: PMC10826083 DOI: 10.1186/s12891-024-07209-3] [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: 10/09/2023] [Accepted: 01/15/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND This study aimed to reveal the posterior tibial slope (PTS) angle with 3 different methods in a large case group in the Turkish population. In addition, the reproducibility of the measurement methods used was questioned while determining the age groups, gender and side relationship of this angle. MATERIALS AND METHODS In our retrospective study, radiographs of both knees were evaluated in all 610 patients (344 women, 56.4%) aged 25-65 years. PTS angles were measured by a radiologist and an orthopedist using anterior tibial cortex (ATC), posterior tibial cortex (PTC) and proximal tibial anatomical axis (PTAA) methods. The relationship of these angles with age group and gender, and the intra-class and inter-class correlations of all three methods were evaluated. RESULTS The mean and standard deviation (SD) of PTS angle was 11.03 ± 2.33° with ATC method, 6.25 ± 2.22° with PTC and 8.68 ± 2.16° with PTAA, and the difference was significant (p < .001). In the evaluation according to age groups, the highest mean PTS angles were detected in cases aged 25-35 (9.63 ± 1.97° [mean ± SD] by PTAA method), and there was a significant difference in comparison with other age groups (p < .05). In comparison with age groups, higher mean PTS angles were found in women and on the right side, but the difference was not statistically significant (p > .05). The intraclass and interclass correlation coefficient (ICC) of all three methods was excellent (ICC > 0.91). CONCLUSION This study emphasizes that the mean PTS angle in Turkish population is higher than the angle values recommended by prosthesis manufacturers, and factors such as patient age and gender should be calculated in order to ensure more effective prostheses to be applied to patients.
Collapse
Affiliation(s)
- Seyhmus Kavak
- Department of Radiology, University of Health Sciences, Gazi Yasargil Training and Research Hospital, Elazig Road, 10th km Uçkuyular Location, Kayapınar, Diyarbakir, 21070, Turkey.
| | - Sehmuz Kaya
- Dursun Odabaşı Medicine Center, Department of Orthopedics and Traumatology, University of Yüzüncü Yıl, Van, Turkey
| |
Collapse
|
|
32
|
Sinno E, Panegrossi G, Rovere G, Cavallo AU, Falez F. Influence of posterior tibial slope on postoperative outcomes after postero-stabilized and condylar-stabilized total knee arthroplasty. Musculoskelet Surg 2023; 107:385-390. [PMID: 36370251 DOI: 10.1007/s12306-022-00768-5] [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: 01/21/2022] [Accepted: 11/04/2022] [Indexed: 06/16/2023]
Abstract
PURPOSE To compare clinical outcomes and surgical times of two different types of total knee arthroplasty(TKA), postero-stabilized(PS) and condylar-stabilized(CS), in relation to posterior tibial slope(PTS) values and the deviation of these values from the surgical technique. METHODS 168 patients undergoing TKA surgery between 2016 and 2020 met our inclusion criteria. For each case, gender, age at surgery, operating time, type of implant and preoperative PTS(preop-PTS) and postoperative PTS(postop-PTS) measurements were collected; difference(∆PTS) between preop-PTS and postop-PTS was also calculated. Short Form 12 Mental and Physical scores(SF-12 M and P) and functional Knee Society Score(fKSS) were collected preoperatively and at a minimum of 12 months postoperatively. Four subgroups were thus created in relation to PS or CS system and postop-PTS value(≤ 5°and > 5°). RESULTS Of the 168 patients, 96 had a PS system and 72 CS system. Performing a CS-TKA took less time than a PS-TKA(p < 0.05). SF-12P showed better results(p < 0.05) in CS-TKA group than PS-TKA, probably because of the younger age of CS-TKA patients(p < 0.05). In the PS > 5° all examined postoperative scores were better(p < 0.05) than PS ≤ 5°, while only fKSS was better(p < 0.05) in CS > 5° than CS ≤ 5°. No significant difference(p > 0.05) in terms of postoperative outcomes between the PS > 5° and CS > 5° was noted, whereas only SF-12P was better in the CS ≤ 5° compared with PS ≤ 5°. Highest values of SF-12 M and fKSS were obtained in the PS ≤ 5°, in which postop-PTS was closer to technique. CONCLUSION When performing a PS-TKA, the best result was obtained with a postop-PTS > 5°, but comparable outcomes between the two systems were evident with postop-PTS > 5°. It is crucial to come as close as possible to the indications reported in surgical technique regardless ∆PTS.
Collapse
Affiliation(s)
- E Sinno
- Orthopaedic and Traumatology Department, S. Spirito Hospital, Lungotevere in Sassia 1, 00193, Rome, Italy.
| | - G Panegrossi
- Orthopaedic and Traumatology Department, S. Spirito Hospital, Lungotevere in Sassia 1, 00193, Rome, Italy
| | - G Rovere
- Orthopaedic and Traumatology Department, S. Spirito Hospital, Lungotevere in Sassia 1, 00193, Rome, Italy
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - A U Cavallo
- Department of Biomedicine and Prevention, University "Tor Vergata", Rome, Italy
- Division of Radiology, San Carlo Di Nancy Hospital", GVM Care and Research, Rome, Italy
| | - F Falez
- Department of Orthopaedics and Traumatology, S. Filippo Neri Hospital, ASL Roma 1 Martinotti 20, 00135, Rome, Via G, Italy
| |
Collapse
|
|
33
|
Lu Y, Pareek A, Yang L, Rouzrokh P, Khosravi B, Okoroha KR, Krych AJ, Camp CL. Deep Learning Artificial Intelligence Tool for Automated Radiographic Determination of Posterior Tibial Slope in Patients With ACL Injury. Orthop J Sports Med 2023; 11:23259671231215820. [PMID: 38107846 PMCID: PMC10725654 DOI: 10.1177/23259671231215820] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 12/19/2023] Open
Abstract
Background An increased posterior tibial slope (PTS) corresponds with an increased risk of graft failure after anterior cruciate ligament (ACL) reconstruction (ACLR). Validated methods of manual PTS measurements are subject to potential interobserver variability and can be inefficient on large datasets. Purpose/Hypothesis To develop a deep learning artificial intelligence technique for automated PTS measurement from standard lateral knee radiographs. It was hypothesized that this deep learning tool would be able to measure the PTS on a high volume of radiographs expeditiously and that these measurements would be similar to previously validated manual measurements. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods A deep learning U-Net model was developed on a cohort of 300 postoperative short-leg lateral radiographs from patients who underwent ACLR to segment the tibial shaft, tibial joint surface, and tibial tuberosity. The model was trained via a random split after an 80 to 20 train-validation scheme. Masks for training images were manually segmented, and the model was trained for 400 epochs. An image processing pipeline was then deployed to annotate and measure the PTS using the predicted segmentation masks. Finally, the performance of this combined pipeline was compared with human measurements performed by 2 study personnel using a previously validated manual technique for measuring the PTS on short-leg lateral radiographs on an independent test set consisting of both pre- and postoperative images. Results The U-Net semantic segmentation model achieved a mean Dice similarity coefficient of 0.885 on the validation cohort. The mean difference between the human-made and computer-vision measurements was 1.92° (σ = 2.81° [P = .24]). Extreme disagreements between the human and machine measurements, as defined by ≥5° differences, occurred <5% of the time. The model was incorporated into a web-based digital application front-end for demonstration purposes, which can measure a single uploaded image in Portable Network Graphics format in a mean time of 5 seconds. Conclusion We developed an efficient and reliable deep learning computer vision algorithm to automate the PTS measurement on short-leg lateral knee radiographs. This tool, which demonstrated good agreement with human annotations, represents an effective clinical adjunct for measuring the PTS as part of the preoperative assessment of patients with ACL injuries.
Collapse
Affiliation(s)
- Yining Lu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Orthopedic Surgery Artificial Intelligence Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Linjun Yang
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Orthopedic Surgery Artificial Intelligence Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Pouria Rouzrokh
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Orthopedic Surgery Artificial Intelligence Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Bardia Khosravi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Orthopedic Surgery Artificial Intelligence Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelechi R. Okoroha
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J. Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | |
Collapse
|
|
34
|
Itthipanichpong T, Uppstrom TJ, V. Menta S, Ranawat AS. Systematic Review of Clinical Outcomes After Proximal Tibia Anterior Closing-Wedge Osteotomy With ACL Reconstruction. Orthop J Sports Med 2023; 11:23259671231210549. [PMID: 38107842 PMCID: PMC10722927 DOI: 10.1177/23259671231210549] [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: 05/22/2023] [Accepted: 06/07/2023] [Indexed: 12/19/2023] Open
Abstract
Background While increased posterior tibial slope (PTS) is an important risk factor for failure after anterior cruciate ligament (ACL) reconstruction, controversy exists regarding indications and outcomes of proximal tibia anterior closing-wedge osteotomy (ACWO) with concomitant ACL reconstruction in patients with ACL tears. Purpose To assess clinical outcomes after combined ACL reconstruction and proximal tibia ACWO. Study Design Systematic review; Level of evidence, 4. Methods In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, we performed a systematic review of the existing literature on ACWO and ACL reconstruction using PubMed (MEDLINE), Cochrane Library, Scopus, and Embase. The search phrases included "anterior closing wedge osteotomy,""anterior closing wedge tibial osteotomy,""anterior closing wedge proximal tibial osteotomy,""anterior cruciate ligament," and "revision anterior cruciate ligament." Non-English publications and single-patient case reports were excluded. Extracted data included study details, patient demographics, patient-reported outcomes (PROs), clinical outcomes, radiographic outcomes, complications, and return-to-sport (RTS) rates. Results A total of 6 studies with 110 patients (110 knees) were included. Two-stage ACWO and ACL reconstruction was reported in 2 studies of 78 patients (71%), while a single-stage technique was reported in 4 studies of 32 patients (29%). ACWO was performed in the setting of primary ACL tear in 23 patients (21%) and in recurrent ACL tear in 87 patients (79%). Patients demonstrated postoperative improvements in Lysholm, pivot-shift test, and side-to-side difference in anterior tibial translation. After ACWO, all studies reported mean postoperative PTS of <10° (range, 4.4°-9.2°). Of patients with available RTS data (n = 43), the same-level RTS rate ranged from 65% to 100%. A two-stage procedure reported in 1 study had a lower RTS rate (n = 13 of 20 [65%]) than that of 2 studies with single-stage procedure (n = 4 of 5 [80%] and n = 18 of 18 [100%]). The overall complication rate was 0.9% to 1.3%, and there were no reported ACL retears. Conclusion The current evidence, which is constrained by the quantity and quality of studies, showed that ACWO with single- or two-stage ACL reconstruction in patients with ACL insufficiency and increased PTS was associated with significant improvements in PROs and high RTS rates.
Collapse
Affiliation(s)
- Thun Itthipanichpong
- The Hospital for Special Surgery, New York, New York, USA
- Department of Orthopaedics, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | | | | |
Collapse
|
|
35
|
Akti S, Akti S, Zeybek H, Celebi NO, Karaguven D, Cankaya D. Anterior metaphyseal angle; much less individual variation in determining the posterior slope of the tibia. J Orthop Sci 2023; 28:1046-1051. [PMID: 35864026 DOI: 10.1016/j.jos.2022.06.017] [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: 02/21/2022] [Revised: 04/19/2022] [Accepted: 06/27/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The question of how to specify the posterior tilt of the tibia during arthroplasty operations remains unclear. The most current opinion is that a design whereby incisions are made in parallel with the individual pre-arthritic posterior tilt will yield better post-operational results. However, the wide range of inter-individual variations of posterior tilt of the tibia and the difficult task of identifying the shaft axis of the tibia through standard lateral radiographs are the main obstacles to this particular method. Therefore, there is a need for another reference line that can be measured with plain radiography and yields less inter-individual variation. The hypothesis of this study was that the angle formed between the anterior metaphyseal line of the proximal tibia and the tibial plateau would prove to be less variable across individuals. METHODS Long-shot radiographs of non-rotating lateral tibias of 85 patients aged between 18 and 38 years were analysed. The angle forming between the anterior metaphyseal line of the proximal tibia and the slope of the tibial plateau, and the posterior slope angle was measured by 2 separate observers using the classical method. RESULTS From the measurements of the posterior slope angle taken with the classical method, 38% (33/85) of the patients were within the ±2-degree range of the mean, and the anterior metaphyseal angle was within ±2 degrees of the mean in 75% (64/85) of the total patients. 44.23% variation (CoV) in posterior slop degrees, 2.73% (CoV) variation in the anterior metaphyseal angle measured by the same researchers. The difference between the percentages of variation was also found to be statistically significant. (z = 15.36, p = 0.000). CONCLUSION The anterior metaphyseal angle can be utilized to predict the individual posterior slope. Nevertheless, further large-scale, multicentre studies are needed to establish a mean value for the population.
Collapse
Affiliation(s)
- Sefa Akti
- Department of Orthopaedics and Traumatology, Cumhuriyet University, Sivas, Turkey.
| | - Serdar Akti
- Department of Radiology, Erbaa State Hospital, Tokat, Turkey
| | - Hakan Zeybek
- Department of Orthopaedics and Traumatology, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Izmir, Turkey
| | - Nilgun Ozgul Celebi
- Department of Statistics, Hacettepe University Faculty of Science, Ankara, Turkey
| | - Dogac Karaguven
- Department of Orthopaedics and Traumatology, Ufuk University, Ankara, Turkey
| | - Deniz Cankaya
- Department of Orthopaedics and Traumatology, Gulhane Teaching and Research Hospital, Ankara, Turkey
| |
Collapse
|
|
36
|
Weiler A, Berndt R, Wagner M, Scheffler S, Schatka I, Gwinner C. Tibial Slope on Conventional Lateral Radiographs in Anterior Cruciate Ligament-Injured and Intact Knees: Mean Value and Outliers. Am J Sports Med 2023; 51:2285-2290. [PMID: 37306059 PMCID: PMC10353028 DOI: 10.1177/03635465231178292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 04/19/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND An increased tibial slope (TS) has been identified as a risk factor for anterior cruciate ligament (ACL) injury and graft failure after ACL reconstruction. However, different imaging modalities are used to determine the TS, resulting in divergent values. Consequently, no reference values and no consensus on thresholds can be reached, which in turn is mandatory for indicating correction osteotomies when facing outlier TS. PURPOSE To determine the mean values of the TS and the incidence of their outliers in large cohorts of patients with ACL-injured and noninjured knees and to determine the feasibility of measuring TS on conventional lateral radiographs (CLRs). STUDY DESIGN Cross-sectional study; Level of evidence 3. METHODS TS of ACL-injured knees (n = 1000, group A) and ACL-intact knees (n = 1000, group B) was measured by 3 experienced examiners. Medial TS was measured on CLRs using the technique of Dejour and Bonnin. Patients with radiographs with poor image quality, osteoarthritis, previous osteotomies, or nondigital radiographs were excluded. The intra- and interrater reliability was calculated using the intraclass correlation coefficient. RESULTS The mean TS was significantly higher in group A than in group B (10.04°± 3° [range, 2°-22°] vs 9.02°± 2.9° [range, 1°-18°], respectively; P < .001). Significantly more participants in group A had TS larger than 12° (≥12°, 32.2% vs 19.8%, P < .001; ≥13°, 20.9% vs 11.1%, P < .001; ≥14°, 13.5% vs 5.7%, P < .001; ≥15°, 8% vs 2.7%, P < .001; ≥16°, 3.7% vs 1.4%, P = .0005), respectively. In contrast, significantly more participatns in group B had TS 8° or less (≤8°, 32.1% vs 42.7%, P < .001; ≤7°, 20% vs 30.9%, P < .001; ≤6°, 12.4% vs 19.8%, P < .001; ≤5°, 6.6% vs 12%, P = .0003; ≤4°, 2.8% vs 5.3%, P = .0045). The intraclass correlation coefficient revealed a good to excellent reliability throughout measurements. CONCLUSION Median values for the TS were 9° for uninjured and 10° for ACL-injured knees on CLRs. Notwithstanding its statistical significance, this finding might be negligible in clinical practice. However, a significantly larger number of outliers were found in the ACL-injured group exceeding a TS of 12° and demonstrating an incremental proportion with increasing TS, serving as a potential threshold for correction osteotomy. Furthermore, CLRs in the largest cohort to date exhibited high reproducibility, proving the feasibility of CLRs as a routine measurement for TS.
Collapse
Affiliation(s)
| | - Rosa Berndt
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Berlin, Germany
| | | | | | - Imke Schatka
- Center for Radiology and Nuclear Medicine, Charité–University Medicine Berlin, Berlin, Germany
| | - Clemens Gwinner
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Berlin, Germany
| |
Collapse
|
|
37
|
Messner MK, McGee AS, Elphingstone JW, Schartung DF, Frazier MB, Schick S, Brabston EW, Momaya AM. The Relationship Between Posterior Tibial Slope and Pediatric Tibial Eminence Fractures. Am J Sports Med 2023; 51:32-37. [PMID: 36453727 DOI: 10.1177/03635465221137888] [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] [Indexed: 12/05/2022]
Abstract
BACKGROUND Tibial eminence fractures are bony avulsions of the anterior cruciate ligament from its insertion on the intercondylar eminence. Numerous anatomic factors have been associated with anterior cruciate ligament injuries, such as posterior tibial slope, but there are few studies evaluating the association with tibial eminence fracture. PURPOSE To compare posterior tibial slope of pediatric patients with and without tibial eminence fractures. We hypothesized that a steeper posterior tibial slope would be associated with tibial eminence fracture. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Patients who underwent surgical treatment of tibial eminence fracture were retrospectively identified between January 2000 and July 2021. Adults aged >20 years and those without adequate imaging were excluded. Controls without gross ligamentous or osseous pathology were identified. Descriptive information and Meyers and McKeever classification were recorded. Posterior tibial slope measurements were obtained by 2 independent orthopaedic surgeons twice, with measurements separated by 3 weeks. Chi-square tests and independent-samples t tests were used to compare posterior tibial slope and patient characteristics. Inter- and intrareviewer variability was determined via the intraclass correlation coefficient. RESULTS A total of 51 patients with tibial eminence fractures and 57 controls were included. By sex, tibial eminence fractures occurred among 34 male and 17 female patients with a mean age of 10.9 years. The posterior tibial slope among those with tibial eminence fractures (9.7°) was not significantly greater than that of controls (8.8°; P = .07). Male patients with a tibial eminence fracture had significantly steeper slopes compared with controls (10.0° vs 8.4°; P = .006); this difference was not observed between female patients and female controls. Patients with a slope ≥1 SD above the mean (12.0°) had 3.8 times greater odds (95% CI, 1.3-11.6; P = .017) of having a tibial eminence fracture. Male patients with a posterior tibial slope >12° had 5.8 times greater odds (95% CI, 1.1-29.1; P = .034) of having a tibial eminence fracture compared with male controls. CONCLUSION Male patients undergoing surgical fixation of a tibial eminence fracture had an increased posterior tibial slope as compared with case-controls. Increased posterior tibial slope may be a risk factor for sustaining a tibial eminence fracture, although the clinical significance of this deserves further investigation.
Collapse
Affiliation(s)
- Mitchell K Messner
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrew S McGee
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joseph W Elphingstone
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David F Schartung
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mason B Frazier
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Samuel Schick
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Eugene W Brabston
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Amit M Momaya
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
|
38
|
Erquicia JI, Gil-Gonzalez S, Ibañez M, Leal-Blanquet J, Combalia A, Monllau JC, Pelfort X. A lower starting point for the medial cut increases the posterior slope in opening-wedge high tibial osteotomy: a cadaveric study. J Exp Orthop 2022; 9:124. [PMID: 36577908 PMCID: PMC9797634 DOI: 10.1186/s40634-022-00562-z] [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: 09/30/2022] [Accepted: 12/16/2022] [Indexed: 12/30/2022] Open
Abstract
PURPOSE The objective of this study was to evaluate the effects on the posterior tibial slope of different distances from the joint line to start the osteotomy and of varying the placement of the opening wedge in high tibial osteotomy. Starting the osteotomy more distally and an incorrect location for the tibial opening wedge were hypothesized to increase the posterior tibial slope. METHODS A cadaveric study was conducted using 12 knees divided into two groups based on the distance from the joint line to the start of the osteotomy: 3 and 4 cm. The preintervention posterior tibial slope was measured radiologically. Once the osteotomy was performed, the medial cortex of the tibia was divided into anteromedial, medial, and posteromedial thirds. A 10° opening wedge was sequentially placed in each third, and the effect on the posterior tibial slope was evaluated radiographically. RESULTS Significant changes were observed only in the 3-cm group (p = 0.02) when the wedge was placed in the anteromedial zone. In contrast, in the 4-cm group, significant differences were observed when the opening wedge was placed at both the medial (p = 0.04) and anteromedial (p = 0.012) zones. CONCLUSION Correct control of the posterior tibial slope can be achieved by avoiding a low point when beginning the osteotomy and placing the opening wedge in the posteromedial third of the tibia when performing an opening-wedge high tibial osteotomy. LEVEL OF EVIDENCE Controlled laboratory study.
Collapse
Affiliation(s)
- Juan Ignacio Erquicia
- grid.488391.f0000 0004 0426 7378Department of Orthopedic Surgery and Traumatology, Althaia Xarxa Assistencial Universitària de Manresa, Carrer Dr. Joan Soler, 1-3, 08243 Manresa, Spain ,IMOVE, Mi Tres Torres, Av. Via Augusta, 281, 08017 Barcelona, Spain
| | - Sergi Gil-Gonzalez
- grid.7080.f0000 0001 2296 0625Department of Orthopedic Surgery and Traumatology, Consorci Corporació Sanitària Parc Taulí. Universitat Autònoma de Barcelona (UAB), Parc del Taulí, 1, 08208 Sabadell, Spain
| | - Maximiliano Ibañez
- grid.7080.f0000 0001 2296 0625ICATME. Hospital Universitari Dexeus, Universitat Autònoma de Barcelona (UAB), Carrer de Sabino Arana 5, 08028 Barcelona, Spain
| | - Joan Leal-Blanquet
- grid.488391.f0000 0004 0426 7378Department of Orthopedic Surgery and Traumatology, Althaia Xarxa Assistencial Universitària de Manresa, Carrer Dr. Joan Soler, 1-3, 08243 Manresa, Spain ,IMOVE, Mi Tres Torres, Av. Via Augusta, 281, 08017 Barcelona, Spain
| | - Andrés Combalia
- grid.5841.80000 0004 1937 0247Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Carrer Casanova 143, 08036 Barcelona, Spain ,grid.5841.80000 0004 1937 0247Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Carrer Casanova 143, 08036 Barcelona, Spain
| | - Juan Carlos Monllau
- grid.7080.f0000 0001 2296 0625ICATME. Hospital Universitari Dexeus, Universitat Autònoma de Barcelona (UAB), Carrer de Sabino Arana 5, 08028 Barcelona, Spain ,grid.7080.f0000 0001 2296 0625Department of Orthopedic Surgery and Traumatology. Hospital del Mar, Universitat Autònoma de Barcelona (UAB), Passeig Marítim, 25, 08003 Barcelona, Spain
| | - Xavier Pelfort
- grid.7080.f0000 0001 2296 0625Department of Orthopedic Surgery and Traumatology, Consorci Corporació Sanitària Parc Taulí. Universitat Autònoma de Barcelona (UAB), Parc del Taulí, 1, 08208 Sabadell, Spain
| |
Collapse
|
|
39
|
Ishii Y, Noguchi H, Sato J, Takahashi I, Ishii H, Ishii R, Ishii K, Toyabe SI. Comparison of the Tibial Posterior Slope Angle Between the Tibial Mechanical Axis and Various Diaphyseal Tibial Axes After Total Knee Arthroplasty. Arthroplast Today 2022; 17:137-141. [PMID: 36158461 PMCID: PMC9493290 DOI: 10.1016/j.artd.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 06/16/2022] [Accepted: 06/23/2022] [Indexed: 11/04/2022] Open
Abstract
Background The posterior tibial slope angle (PTS) is crucial for sagittal alignment after total knee arthroplasty (TKA). This study aimed to determine which PTS based on the lateral view of standard knee radiographs (LSKRs; 36 × 43 cm) reflects the PTS based on a full-length lateral tibial radiograph (FLTR). Methods A total of 290 patients (355 knees) who underwent primary TKA were retrospectively recruited. Cross-sectional views from the 3-dimensional digital model of the tibial prosthesis and bone complex in the sagittal plane were used as FLTRs and LSKRs. Considering the region 21.5 cm proximal to the site of FLTR as the spot for LSKR to determine the 5 tibial diaphyseal axes, the axis that simulates the PTS as determined by the tibial mechanical axis between the center of the tibial component and the ankle plafond in LSKR was determined and compared. Results PTS (α5) defined by the line connecting the midpoints of tibial width between the region 10-cm distal to the knee joint and the distal end of the tibia based on LSKR revealed the least mean difference (0.13° ± 1.00°) and the strongest correlation (P < .001, r = 0.948) with PTS based on FLTR (α0). The number of knees in α5, indicating a difference of <2° from α0, was 333 of 355 (93.8%). The equivalence test results indicated that α0 and α5 were statistically equivalent within a difference of 2° (P < .001). Conclusions PTS (α5) can be used as a clinically reliable substitution of the true PTS on an FLTR for evaluating sagittal alignment after TKA.
Collapse
|
|
40
|
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: 2.3] [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.
Collapse
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.
| |
Collapse
|
|
41
|
Bayram E, Şener N, Korkmaz M, Yıldırım C, Aydın M, Yurdaışık I, Çetinus ME. Internal tibial torsion is associated with medial meniscus posterior horn tears. Knee Surg Sports Traumatol Arthrosc 2022; 31:2251-2256. [PMID: 36153779 DOI: 10.1007/s00167-022-07173-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/15/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Risk factors for meniscal tears play a decisive role in deciding on treatment and rehabilitation. The purpose of this study was to investigate the effect of tibial rotation on medial meniscus posterior horn tears (MMPHTs). METHODS This study is a retrospective case-control study. Fifty patients with meniscal tears and 57 knees with intact meniscus were compared. Tibial rotation, femoral version, tibial slope and knee varus were measured in each participant. Knee osteoarthritis was classified according to the Kellgren-Lawrence classification. Demographic characteristics were noted. RESULTS There were significant differences in the mean tibial torsion angles and mean mechanical axes between the groups. The mean tibial rotation and mean mechanical axis were 26.3° ± 6.7 and 3.7° ± 2.7 in the MMPHT group and 30.3° ± 8.4 and 2.05° ± 2.7 in the control group, respectively (p = 0.008, p = 0.002). CONCLUSION The current retrospective study has shown that tibial rotation is markedly reduced in patients with MMPHTs. Although the actual mechanism is not clear, the internal torsion of the tibia causes a decrease in the foot progression angle and increases the knee adduction moment, which in turn increases the medial tibial contact pressure. Internal torsion of the tibia, such as knee varus, may play a role in the aetiology of MMPHTs by this way. Whilst there was a significant difference in the mean varus and tibial torsion between the groups, there was no significant difference in the mean femoral version or tibial slope. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Erhan Bayram
- Department of Orthopedics and Traumatology, Gaziosmapanasa Medicalpark Hospital, Istinye University, Merkez Mah., Çukurçeşme Sok. No: 57-59, Gaziosmanpaşa Medicalpark Hospital, Bayrampaşa, Istanbul, Turkey.
| | - Nurullah Şener
- Department of Orthopedics and Traumatology, Gaziosmapanasa Medicalpark Hospital, Istinye University, Merkez Mah., Çukurçeşme Sok. No: 57-59, Gaziosmanpaşa Medicalpark Hospital, Bayrampaşa, Istanbul, Turkey
| | - Musa Korkmaz
- Department of Orthopedics and Traumatology, Gaziosmapanasa Medicalpark Hospital, Istinye University, Merkez Mah., Çukurçeşme Sok. No: 57-59, Gaziosmanpaşa Medicalpark Hospital, Bayrampaşa, Istanbul, Turkey
| | - Cem Yıldırım
- Department of Orthopedics and Traumatology, Çam Ve Sakura Training and Research Hospital, Istanbul, Turkey
| | - Mahmud Aydın
- Department of Orthopedics and Traumatology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Işıl Yurdaışık
- Department of Radiology, Gaziosmapanasa Medicalpark Hospital, Istinye University, Istanbul, Turkey
| | - Mahmut Ercan Çetinus
- Department of Orthopedics and Traumatology, Gaziosmapanasa Medicalpark Hospital, Istinye University, Merkez Mah., Çukurçeşme Sok. No: 57-59, Gaziosmanpaşa Medicalpark Hospital, Bayrampaşa, Istanbul, Turkey
| |
Collapse
|
|
42
|
Anterior Closing Wedge Osteotomy for Failed Anterior Cruciate Ligament Reconstruction: State of the Art. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202209000-00006. [PMID: 36121766 PMCID: PMC9484815 DOI: 10.5435/jaaosglobal-d-22-00044] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 07/19/2022] [Indexed: 11/18/2022]
Abstract
The sagittal anatomy of the proximal tibia has a bearing on the forces exerted on the cruciate ligaments. A high posterior tibial slope is now a well-known risk factor causing failure of anterior cruciate ligament (ACL) reconstructions. The posterior slope can be calculated on short or full-length radiographs, MRI scans, or three-dimensional CT scans. Reducing the slope surgically by a sagittal tibial osteotomy is biomechanically protective for the ACL graft. An anterior closing wedge osteotomy may be contemplated when the lateral tibial slope is greater than 12°, in the setting of ACL reconstruction failure(s). Careful surgical planning to calculate the correction, taking into account knee hyperextension and patella height, is critical to avoid complications. It can be done above, at, or below the tibial tuberosity level. A transtuberosity correction can be done with or without a tibial tubercle osteotomy. This complex surgery can be conducted safely by meticulous execution to protect the posterior hinge and neurovascular structures and achieving stable fixation with staples. The limited literature available justifies the usage of anterior closing wedge osteotomy in appropriately selected patients.
Collapse
|
|
43
|
Jia G, Tang Y, Liu Z, Peng B, Da L, Yang J, Liu X, Ma M, Han H, Wu M, Geng B, Xia Y, Teng Y. 3D Killer Turn Angle in Transtibial Posterior Cruciate Ligament Reconstruction Is Determined by the Graft Turning Angle both in the Sagittal and Coronal Planes. Orthop Surg 2022; 14:2298-2306. [PMID: 35920590 PMCID: PMC9483043 DOI: 10.1111/os.13411] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/28/2022] [Accepted: 06/18/2022] [Indexed: 11/29/2022] Open
Abstract
Objective During the transtibial posterior cruciate ligament (PCL) reconstruction, surgeons commonly pay more attention to the graft turning angle in the sagittal plane (GASP), but the graft turning angle in the coronal plane (GACP) is always neglected. This study hypothesized that the three‐dimensional (3D) killer turn angle was determined by both the GASP and GACP, and aimed to quantitively analyze the effects of the GASP and GACP on the 3D killer turn angle. Methods This was an in‐vitro computer simulation study of transtibial PCL reconstruction using 3D knee models. Patients with knee injuries who were CT scanned were selected from the CT database (April 2019 to January 2021) at a local hospital for reviewing. A total of 60 3D knees were simulated based on the knees' CT data. The femoral and tibial PCL attachment were located on the 3D knee model using the Rhinoceros software. The tibial tunnels were simulated based on different GASP and GACP. The effects of the GASP and GACP on the 3D killer turn angle were quantitatively analyzed. One‐way analysis of variance was used to compare the outcomes in different groups. The regression analysis was performed to identify variables of the GASP and GACP which significantly affected 3D killer turn angle. Results The 3D killer turn angle showed a significant proportional relationship not only with the GASP (r2 > 0.868, P < 0.001), but also with the GACP (r2 > 0.467, P < 0.001). Every 10° change of the GACP caused 2.8° to 4.4° change of the 3D killer turn angle, whereas every 10° change of the GASP caused 6.4° to 9.2° change of the 3D killer turn angle. Conclusions The 3D killer turn angle was significantly affected by both the GASP and GACP. During the transtibial PCL reconstruction, the proximal anterolateral tibial tunnel approach could increase the 3D killer turn angle more obviously compared with the most distal anteromedial tibial tunnel approach. To minimize the killer turn effect, both the GASP and GACP were required to be considered to increase.
Collapse
Affiliation(s)
- Gengxin Jia
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People's Republic of China
| | - Yuchen Tang
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People's Republic of China
| | - Zhongcheng Liu
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People's Republic of China
| | - Bo Peng
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People's Republic of China
| | - Lijun Da
- Department of Oncology, Lanzhou University Second Hospital, Lanzhou University, Lanzhou City, People's Republic of China
| | - Jun Yang
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People's Republic of China
| | - Xiaolong Liu
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People's Republic of China
| | - Ming Ma
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People's Republic of China
| | - Hua Han
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People's Republic of China
| | - Meng Wu
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People's Republic of China
| | - Bin Geng
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People's Republic of China
| | - Yayi Xia
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People's Republic of China
| | - Yuanjun Teng
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, People's Republic of China
| |
Collapse
|
|
44
|
Clinger BN, Plaster S, Passarelli T, Marshall J, Wascher DC. Differentiation in Posterior Tibial Slope by Sex, Age, and Race: A Cadaveric Study Utilizing 3-Dimensional Computerized Tomography. Am J Sports Med 2022; 50:2698-2704. [PMID: 35853159 DOI: 10.1177/03635465221108187] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Posterior tibial slope (PTS) has recently gained increased attention for its possible role in anterior cruciate ligament and posterior cruciate ligament injury. The possible differences among age, sex, and ethnicity in PTS have not yet been reported. PURPOSE To describe demographic variances of proximal tibial anatomy and to detect differences in regard to ethnicity, sex, and age. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS In total, 250 cadaveric specimens with full-body computerized tomography scans from the New Mexico Descendant Imaging Database were randomly selected (inclusion/exclusion criteria: older than 18 years, complete imaging of the knee without previous surgery or arthroplasty) and reviewed by 3 independent observers measuring medial posterior tibial slope (MPTS), lateral posterior tibial slope (LPTS), and global posterior tibial slope (PTS), which was calculated as the mean of the MPTS and LPTS. Individuals were evenly divided among male and female and ethnicities/races: African American/Black, Asian American, Hispanic, Native American, and White. Intraclass correlation coefficient was calculated for interobserver reliability and analysis of variance statistical testing to determine statistical significance between groups. Fisher exact test was also used to understand PTS differences among ethnicities when looking at clinically significant values for potential ligamentous injury. RESULTS Measurements were obtained from 250 specimens with a mean age of 49.4 years (range, 19 to 103 years). The mean PTS was 8.92° (range, -9.4° to 14.95°). Asian Americans had a 1.7° greater mean MPTS than Whites (P = .016), and African Americans/Blacks had a 1.6° greater mean PTS than Whites (P = .022). No difference in mean PTS was seen between age and sex. When looking at clinically significant PTS, 61 (24.4%) individuals had tibial slopes <6° or >12°, 32 (12.8%) and 29 (11.6%), respectively. Statistically significant differences were seen among ethnicities with PTS <6° (P = .017) but not with PTS >12° (P = .106). No sex-based differences were seen in the percentage of specimens with a PTS of >12° or <6°. CONCLUSION Among ethnicities, African Americans/Blacks and Asian Americans have increased PTS in comparison with Whites. Nearly 25% of individuals have clinically significant slopes of <6° or >12°, with no difference in tibial slope among sex or age groups.
Collapse
Affiliation(s)
- Bryce N Clinger
- Department of Orthopaedics and Rehabilitation, University of New Mexico Hospitals, Albuquerque, New Mexico, USA
| | - Scott Plaster
- Department of Orthopaedics and Rehabilitation, University of New Mexico Hospitals, Albuquerque, New Mexico, USA
| | - Talia Passarelli
- Univeristy of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Justin Marshall
- Department of Radiology, University of New Mexico Hospitals, Albuquerque, New Mexico, USA
| | - Daniel C Wascher
- Department of Orthopaedics and Rehabilitation, University of New Mexico Hospitals, Albuquerque, New Mexico, USA
| |
Collapse
|
|
45
|
Jiang J, Liu Z, Wang X, Xia Y, Wu M. Increased Posterior Tibial Slope and Meniscal Slope Could Be Risk Factors for Meniscal Injuries: A Systematic Review. Arthroscopy 2022; 38:2331-2341. [PMID: 35066109 DOI: 10.1016/j.arthro.2022.01.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this systematic review was to summarize the available evidence and examine the relation between the posterior tibial slope (PTS) and meniscal slope (MS) and the incidence of meniscal injury. METHODS PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science were searched from inception to February 23, 2021. Cohort studies investigating the association between PTS or MS and the risk of meniscal injury were included. Two authors independently conducted the literature search, data extraction, and quality assessment. RESULTS Sixteen studies with a total of 2,670 patients were included. For meniscal injury with an anterior cruciate ligament tear, the lateral PTS in the lateral meniscal root tear group (range, 8.0°-12.6°) was significantly higher than that in the control group (range, 4.0°-10.7°). Furthermore, there appeared to be a relation between a greater medial MS and the presence of a ramp lesion (range, 2.6°-6.7° for ramp lesion vs 2.0°-5.1° for control). For degenerative meniscal injury, the medial PTS in the medial meniscal posterior root tear group (range, 6.15°-10.4°) was significantly greater than that in the control group (range, 4.0°-9.8°). CONCLUSIONS On the basis of the available evidence, for meniscal injury with an anterior cruciate ligament tear, an increased lateral PTS was associated with a higher risk of lateral meniscal tears and lateral meniscal posterior root tears. Furthermore, there appeared to be a relation between an increased medial MS and a higher risk of ramp lesions. For degenerative meniscal injury, most of the included studies showed that a larger medial PTS could increase the risk of medial meniscal tears and medial meniscal posterior root tears. LEVEL OF EVIDENCE Level III, systematic review of Level III studies.
Collapse
Affiliation(s)
- Jin Jiang
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China
| | - Zhongcheng Liu
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China
| | - Xiuyuan Wang
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China
| | - Yayi Xia
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China.
| | - Meng Wu
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China
| |
Collapse
|
|
46
|
Yamagami R, Inui H, Taketomi S, Kono K, Kawaguchi K, Sameshima S, Kage T, Tanaka S. Proximal tibial morphology is associated with risk of trauma to the posteromedial structures during tibial bone resection reproducing the anatomical posterior tibial slope in bicruciate-retaining total knee arthroplasty. Knee 2022; 36:1-8. [PMID: 35381571 DOI: 10.1016/j.knee.2022.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 07/23/2021] [Accepted: 03/21/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND A tibial cut with the native posterior tibial slope (PTS) is a theoretical prerequisite in bicruciate-retaining total knee arthroplasty (BCRTKA) to regain physiological knee kinematics. The present study reveals tibial morphological risk factors of trauma to the posteromedial structures of the knee during tibial bone resection in BCRTKA. METHODS Fifty patients undergoing BCRTKA for varus knee osteoarthritis were analyzed. A three-dimensional tibial bone model was reconstructed using a computed tomography-based preoperative planning system, and the coronal tibial slope (CTS) and medial PTS (MPTS) were measured. Then, we set the simulated tibial cutting plane neutral on the coronal plane, posteriorly inclined in accordance with the MPTS on the sagittal plane, and 9 mm below the surface of the subchondral cortical bone (i.e., 11 mm below the surface of the cartilage) of the lateral tibial plateau. The association between the tibial morphology and the distance from the simulated cutting plane to the semimembranosus (SM) insertion (Dsm) was analyzed. RESULTS Of the 50 patients, 19 (38%) had negative Dsm values, indicating a cut into the SM (namely, below the posterior oblique ligament) insertion. The MPTS was negatively correlated with Dsm (r = -0.396, p = 0.004), whereas the CTS was positively correlated with Dsm (r = 0.619, p < 0.001). On multivariate linear regression analysis, the MPTS and CTS were independent predictors of Dsm. CONCLUSION In the setting of tibial cuts reproducing the native MPTS in BCRTKA, patients with larger PTS and smaller CTS had more risk of trauma to the posteromedial structures.
Collapse
Affiliation(s)
- Ryota Yamagami
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Inui
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Shuji Taketomi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kenichi Kono
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kohei Kawaguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shin Sameshima
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomofumi Kage
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
|
47
|
Ramos Marques N, Morais B, Barreira M, Nóbrega J, Ferrão A, Torrinha Jorge J. Anterior Slope Correction-Flexion Osteotomy in Traumatic Genu Recurvatum. Arthrosc Tech 2022; 11:e889-e893. [PMID: 35646563 PMCID: PMC9134481 DOI: 10.1016/j.eats.2022.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
A decreased posterior tibial slope has been associated with an increased risk of posterior cruciate ligament failure, anterior knee pain, and premature knee osteoarthritis. Trauma is a common cause of osseous genu recurvatum. Surgical management is recommended to correct the tibial slope and prevent knee pain and osteoarthritis progression. This article discusses our preferred treatment using a proximal tibial opening-wedge osteotomy for surgical management of genu recurvatum secondary to significant anterior tibial slope.
Collapse
Affiliation(s)
- Nuno Ramos Marques
- Deparment of Orthopedic Surgery, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| | - Bruno Morais
- Deparment of Orthopedic Surgery, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| | - Mariana Barreira
- Deparment of Orthopedic Surgery, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| | - João Nóbrega
- Deparment of Orthopedic Surgery, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| | - Ana Ferrão
- Deparment of Orthopedic Surgery, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| | - João Torrinha Jorge
- Deparment of Orthopedic Surgery, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| |
Collapse
|
|
48
|
Teng Y, Jia G, Da L, Peng B, Liu Z, Han H, Wu M, Xia Y. The Permissive Safe Angle of the Tibial Tunnel in Transtibial Posterior Cruciate Ligament Reconstruction: A Three-Dimensional Simulation Study. Orthop Surg 2022; 14:1193-1202. [PMID: 35478490 PMCID: PMC9163973 DOI: 10.1111/os.13266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 03/17/2022] [Accepted: 03/21/2022] [Indexed: 11/29/2022] Open
Abstract
Objective To determine the permissive safe angle (PSA) of the tibial tunnel in transtibial posterior cruciate ligament (PCL) reconstruction based on a three‐dimensional (3D) simulation study. Methods This was a computer simulation study of transtibial PCL reconstruction using 3D knee models. CT images of 90 normal knee joints from 2017 to 2020 were collected in this study, and 3D knee models were established based on CT data. The tunnel approaches were subdivided into the anterior 1/3 of the anteromedial tibia (T1), middle 1/2 of the anteromedial tibia (T2), the tibial crest (T3), anterior 1/3 of the anterolateral tibia (T4), middle 1/2 of the anterolateral tibia (T5). Five tibial tunnels (T1–T5) were simulated on the 3D knee models. The PSAs, in different tibial tunnel approaches were measured, and subgroup analyses of sex, age and height were also carried out. Results The mean PSAs of the tibial tunnels with 5 different approaches (T1–T5) were 58.49° ± 6.82°, 61.14° ± 6.69°, 56.12° ± 7.53°, 52.01° ± 8.89° and 49.90° ± 10.53°, respectively. The differences of the mean PSAs between the anteromedial and anterolateral approaches were significant (P < 0.05). However, there was no significant difference of the mean PSA value between the two anteromedial tibial tunnel approaches (T1–T2) (P > 0.05), as well as between the two anterolateral tibial tunnel approaches (T4–T5). The patient's anthropomorphic characteristics of sex, age, and height were not associated with the PSAs. Conclusions The PSA varied with the anteromedial, tibial crest and anterolateral approaches for transtibial PCL reconstruction, and surgeons should limit the PCL drill guide by referring to the specific PSA for different surgical approaches.
Collapse
Affiliation(s)
- Yuanjun Teng
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, PR China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, PR China
| | - Gengxin Jia
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, PR China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, PR China
| | - Lijun Da
- Department of Oncology, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, PR China
| | - Bo Peng
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, PR China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, PR China
| | - Zhongcheng Liu
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, PR China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, PR China
| | - Hua Han
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, PR China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, PR China
| | - Meng Wu
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, PR China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, PR China
| | - Yayi Xia
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, PR China.,Orthopaedics Key Laboratory of Gansu Province, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, PR China
| |
Collapse
|
|
49
|
Chen Y, Ding J, Dai S, Yang J, Wang M, Tian T, Deng X, Li B, Cheng G, Liu J. Radiographic measurement of the posterior tibial slope in normal Chinese adults: a retrospective cohort study. BMC Musculoskelet Disord 2022; 23:386. [PMID: 35473639 PMCID: PMC9040249 DOI: 10.1186/s12891-022-05319-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 04/11/2022] [Indexed: 01/16/2023] Open
Abstract
Background Measurement of the posterior tibial slope (PTS) angle has important applications in total knee replacement surgery, high tibial osteotomy, and anterior cruciate ligament reconstruction. This study aimed to determine the mean PTS of knee joints in healthy Chinese adults, and provide data to guide knee surgery in China. Methods A retrospective analysis of 1257 (n = 1233, 50.4% male) plain X-ray films of participants aged 25–59 years was performed. The picture archiving and communication system was used for PTS measurement. The PTS was defined as the angle between the vertical line of the tangent of the anterior tibial cortex of the proximal tibia, and the tangent line of the tibial cortex. Two imaging physicians conducted the PTS measurements independently, and both the inter- and intraclass correlation coefficients (ICCs) were calculated. Results The mean PTS value was 7.68 ± 3.84° (range: 0–21°). The left PTS was significantly smaller in males than in females (7.22 ± 3.89 vs 8.05 ± 3.60; P = 0.005). Additionally, the PTS in participants aged 25–29 years was significantly larger than that in the other age groups (Left side: 8.64 ± 3.73 vs 6.92 ± 3.42, 7.42 ± 3.75, 7.53 ± 3.98; P < 0.001 and Right side: 8.68 ± 3.84 vs 7.48 ± 4.21, 7.13 ± 3.64, 7.66 ± 3.80; P = 0.004). There were no significant differences in PTS between the left and right sides. Two-way analysis of variance suggested that the differences in PTS between age groups were not affected by sex. The interobserver ICC was 0.91 (95% confidence interval [CI]: 0.85–0.94), and the intraobserver ICC was 0.90 (95% CI: 0.82–0.94). Conclusions This study demonstrated that there were significant differences in PTS based on sex and age, highlighting the need to provide individualized treatment for knee surgery. It provided valuable information regarding the normal PTS values in Chinese adults and presented regionalised data to guide knee surgery.
Collapse
Affiliation(s)
- Yong Chen
- Department of Radiology, The Affiliated Hospital of Hangzhou Normal University, Wenzhoulu, Gongshu District, Hangzhou City, 310000, Zhejiang Province, China
| | - Jianping Ding
- School of Clinical Medicine, Hangzhou Normal University, Hangzhou, China
| | - Siyu Dai
- School of Clinical Medicine, Hangzhou Normal University, Hangzhou, China
| | - Jiao Yang
- Department of Radiology, the Second Affiliated Hospital of Xi'an Medical University, Xi'an, China
| | - Mengke Wang
- The Second People's Hospital of Chun'an County, Hangzhou, China
| | - Tian Tian
- School of Clinical Medicine, Hangzhou Normal University, Hangzhou, China
| | - Xiaolong Deng
- School of Clinical Medicine, Hangzhou Normal University, Hangzhou, China
| | - Boyi Li
- School of Clinical Medicine, Hangzhou Normal University, Hangzhou, China
| | - Guohua Cheng
- Hangzhou Jianpei Technology Co., Ltd, Hangzhou, China
| | - Jie Liu
- Department of Radiology, The Affiliated Hospital of Hangzhou Normal University, Wenzhoulu, Gongshu District, Hangzhou City, 310000, Zhejiang Province, China.
| |
Collapse
|
|
50
|
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: 19] [Impact Index Per Article: 6.3] [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.
Collapse
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
| | | |
Collapse
|