scholarly journals The Ratio of Tibial Slope and Meniscal Bone Angle for the Prediction of ACL Reconstruction Failure Risk

2018 ◽  
Vol 04 (03) ◽  
pp. e152-e159 ◽  
Author(s):  
Steffen Sauer ◽  
Robert English ◽  
Mark Clatworthy
Keyword(s):  
Anterior Cruciate Ligament ◽  
High Risk ◽  
Graft Failure ◽  
Cruciate Ligament ◽  
Tibial Slope ◽  
Acl Graft ◽  
Failure Risk ◽  
Increased Risk ◽  
Acl Failure ◽  
Anterior Cruciate

Background A growing body of research is indicating that the tibial slope and the geometry of the tibiofemoral meniscal–cartilage interface may affect the risk of anterior cruciate ligament reconstruction (ACLR) failure. Increased lateral tibial posterior slope (LTPS) and reduced meniscal bone angle (MBA) are associated with increased risk of anterior cruciate ligament (ACL) injury. The significance of a LTPS–MBA ratio regarding the prediction of ACL failure risk remains unknown. As LTPS and MBA may eventually potentiate or neutralize each other, it is expected that a low LTPS–MBA ratio is associated with high chance of ACL graft survival while a high LTPS–MBA ratio is associated with high risk of ACL failure. Material and Methods Out of 1,487 consecutive patients who underwent hamstring ACLR between August 2000 and May 2013, 54 ACLR failures with intact lateral menisci were included in this study and matched one-to-one with 54 control participants by age, sex, graft, surgical technique, and graft fixation method. Control participants had undergone ACLR without signs of lateral meniscal injury, graft failure, or insufficiency. MBA and LTPS were assessed on magnetic resonance imaging. Logistic regression was used to identify LTPS/MBA key cut-off ratios. Results In this cohort, a LTPS–MBA ratio under 0.27 was associated with a 28% risk of ACLR failure (36% of patients), while a ratio exceeding 0.42 was associated with an 82% risk of ACLR failure (31% of patients). The odds of ACL failure increased by 22.3% per reduction of 1 degree in MBA (odds ratio [OR], 1.22; 95% limits, 1.1–1.34). No significant association was found between LTPS and the risk of ACL graft failure in transtibial ACLR, while the odds of ACL failure increased by 34.9% per degree of increasing LTPS in transportal ACLR (OR, 1.34; 95% limits, 1.01–1.79). No significant correlation was found between MBA and LTPS (p = 0.5). Conclusion Reduced MBA was associated with significantly increased risk of ACL graft failure. A ratio of LTPS and MBA was found to be useful for the prediction of ACLR failure risk and may preoperatively help to identify patients at high risk of ACLR failure. This may have implications for patient counseling and the indication of additional extra-articular stabilizing procedures.

scholarly journals GRAFT CHOICE FOR ADOLESCENT ATHLETES RETURNING TO HIGH-RISK SPORTS: A MATCHED COHORT ANALYSIS OF PATELLAR TENDON AND HAMSTRING AUTOGRAFTS

2019 ◽  
Vol 7 (3_suppl) ◽  
pp. 2325967119S0007
Author(s):  
Crystal Perkins ◽  
Michael Busch ◽  
Melissa Christino ◽  
Belinda Schaafsma ◽  
S. Clifton Willimon
Keyword(s):  
Anterior Cruciate Ligament ◽  
High Risk ◽  
Acl Reconstruction ◽  
Patellar Tendon ◽  
Graft Failure ◽  
Cruciate Ligament ◽  
Graft Rupture ◽  
Graft Choice ◽  
Anterior Cruciate

Background: Graft selection for skeletally mature adolescents undergoing anterior cruciate ligament (ACL) reconstruction is guided by surgeon and patient preference. In young patients returning to high-risk cutting and pivoting sports, graft rupture is the most feared complication of ACL reconstruction. Some studies have demonstrated slightly lower rates of graft failure and decreased laxity in the short term associated with patellar tendon (BTB) autografts as compared to hamstring (HS) autografts, but these studies are limited by their heterogeneity of ages and activity level1-3. The purpose of this study is to compare the rates of graft failure between BTB and HS ACL reconstruction cohorts matched by age, sex, and sport. Methods: A single-institution retrospective review was performed of consecutive patients less than 19 years of age treated with ACL reconstructions using either patellar tendon (BTB) or hamstring (HS) autograft performed by a single surgeon. Skeletally mature or nearly mature patients in “high-risk” ACL injury sports (basketball, football, soccer, lacrosse, and gymnastics) were initially treated with hamstring autografts but the graft preference transitioned to BTB autografts as the preferred graft choice during the study period. This transition in graft preference for adolescents participating in “high risk” sports allows for a comparison of outcomes based on graft types. Inclusion criteria were ages 13 – 18 years, participation in a “high risk” sport, and minimum 6-month follow-up. The two cohorts of patients were matched by age, gender, and sport. The primary outcome measure was graft rupture. Results: One hundred fifty-two patients with an average age of 16 years (range 13 – 18 years) underwent ACL reconstruction during the study period. There were 71 BTB reconstructions and 81 HS reconstructions. There were 64 females and 88 males. There was no difference in age, sex, BMI, or laterality between groups. There were more patients who played soccer in the BTB cohort (44%) vs HS cohort (20%) and fewer who played basketball in the BTB cohort (24%) vs HS cohort (41%), p = 0.005. There were no differences between the BTB and HS cohorts in terms of meniscus tears (61% v 72%, p = 0.15), meniscus repair (21% v 32%, p = 0.13), or partial meniscectomy (32% v 33%, p = 0.90). Mean duration of follow-up was 28 months (range 7-57 months). There was no difference in follow-up between cohorts (BTB 28 months and HS 29 months, p = 0.19). There were a total of 16 graft ruptures (10.5%). There was no difference in the rate of graft rupture between cohorts (BTB 8.5% vs HS 12.3%, p = 0.60). Mean time to graft rupture was 21 months (range 8 – 35 months) and Kaplan-Meier survival curves demonstrated no difference between cohorts. Conclusions: ACL reconstruction in adolescents returning to high-risk sports can be performed utilizing BTB or HS autografts with similar rates of graft rupture. There is a trend toward lower rates of graft rupture associated with BTB autografts, but additional patients will be necessary to determine if this trend will become a statistically significant difference. Beynnon BD, Johnson RJ, Fleming BC, et al. Anterior cruciate ligament replacement: comparison of bone-patellar tendon bone grafts with two-strand hamstring grafts. A prospective, randomized study. J Bone Joint Surg Am 2002;84(9):1503-1513. Ho B, Edmonds EW, Chambers HG et al. Risk factors for early ACL reconstruction failure in pediatric and adolescent patients: a review of 561 cases. J Pediatr Orthop 2016. Samuelsen BT, Webster KE, Johnson NR, et al. Hamstring autograft versus patellar tendon autograft for ACL reconstruction: is there a difference in graft failure rate? A meta-analysis of 47,613 patients. Clin Orthop Relat Res 2017;475(10):2459-2468.

Tibial Slope and Its Effect on Force in Anterior Cruciate Ligament Grafts: Anterior Cruciate Ligament Force Increases Linearly as Posterior Tibial Slope Increases

2019 ◽  
Vol 47 (2) ◽  
pp. 296-302 ◽  
Author(s):  
Andrew S. Bernhardson ◽  
Zachary S. Aman ◽  
Grant J. Dornan ◽  
Bryson R. Kemler ◽  
Hunter W. Storaci ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Linear Relationship ◽  
Sagittal Plane ◽  
Cruciate Ligament ◽  
Tibial Slope ◽  
Tibial Osteotomy ◽  
Acl Graft ◽  
Posterior Tibial ◽  
Axially Loaded ◽  
Anterior Cruciate

Background: Previous work has reported that increased tibial slope is directly correlated with increased anterior tibial translation, possibly predisposing patients to higher rates of anterior cruciate ligament (ACL) tears and causing higher rates of ACL graft failures over the long term. However, the effect of changes in sagittal plane tibial slope on ACL reconstruction (ACLR) graft force has not been well defined. Purpose/Hypothesis: The purpose of this study was to quantify the effect of changes in sagittal plane tibial slope on ACLR graft force at varying knee flexion angles. Our null hypothesis was that changing the sagittal plane tibial slope would not affect force on the ACL graft. Study Design: Controlled laboratory study. Methods: Ten male fresh-frozen cadaveric knees had a posterior tibial osteotomy performed and an external fixator placed for testing and accurate slope adjustment. Following ACLR, specimens were compressed with a 200-N axial load at flexion angles of 0°, 15°, 30°, 45°, and 60°, and the graft loads were recorded through a force transducer clamped to the graft. Tibial slope was varied between −2° and 20° of posterior slope at 2° increments under these test conditions. Results: ACL graft force in the loaded testing state increased linearly as slope increased. This effect was independent of flexion angle. The final model utilized a 2-factor linear mixed-effects regression model and noted a significant, highly positive, and linear relationship between tibial slope and ACL graft force in axially loaded knees at all flexion angles tested (slope coefficient = 0.92, SE = 0.08, P < .001). Significantly higher graft force was also observed at 0° of flexion as compared with all other flexion angles for the loaded condition (all P < .001). Conclusion: The authors found that tibial slope had a strong linear relationship to the amount of graft force experienced by an ACL graft in axially loaded knees. Thus, a flatter tibial slope had significantly less loading of ACL grafts, while steeper slopes increased ACL graft loading. Our biomechanical findings support recent clinical evidence of increased ACL graft failure with steeper tibial slope secondary to increased graft loading. Clinical Relevance: Evaluation of the effect of increasing tibial slope on ACL graft force can guide surgeons when deciding if a slope-decreasing proximal tibial osteotomy should be performed before a revision ACLR. Overall, as slope increases, ACL graft force increases, and in our study, flatter slopes had lower ACL graft forces and were protective of the ACLR graft.

Anterior Closing Wedge Proximal Tibial Osteotomy and Revision Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft

2021 ◽  
Vol 1 (5) ◽  
pp. 263502542110227
Author(s):  
Katie Geers ◽  
Benjamin Ormseth ◽  
Andrew Garrone ◽  
Robert Siston ◽  
Robert A. Duerr
Keyword(s):  
Anterior Cruciate Ligament ◽  
Risk Factor ◽  
Graft Failure ◽  
Cruciate Ligament ◽  
Quadriceps Tendon ◽  
Acl Injuries ◽  
Acl Graft ◽  
Closing Wedge ◽  
Anterior Cruciate ◽  
Tendon Autograft

Background: Anterior cruciate ligament (ACL) ruptures are among the most common injuries in young athletes and active adults. Reconstruction of the ACL most often leads to good functional outcomes and return to full activities. However, a number of patients experience ACL graft failures requiring revision surgery. The reasons for ACL graft failure are often multifactorial, though recent attention has been given to elevated posterior tibial slope (PTS) as a risk factor for recurrent ACL injuries. Indications: In patients with 2 or more ACL reconstruction failures with a PTS ≥12 degrees, anterior closing wedge proximal tibia osteotomy (ACWPTO) may be indicated to reduce the risk of recurrent ACL graft failure and allow return to full activities. Technique Description: This surgical technique video demonstrates the ACWPTO using a case example in a young athlete. Preoperative templating on lateral radiograph is used to determine the amount of correction for the closing wedge. The osteotomy is completed using K-wires and a free hand biplanar cutting technique with the tibial tubercle left in place. This is performed with a concomitant revision ACL reconstruction using quadriceps tendon autograft. Results: There are 2 small cases series published with good clinical outcomes and return to sport activities. No ACL graft failures were reported in either study with short-term follow-up. Discussion: In this surgical technique video, we review the literature indicating elevated PTS as a risk factor in ACL injuries and recurrent ACL graft failures. We highlight important technique pearls and pitfalls to avoid complications during the surgical demonstration. Finally, we review postoperative rehabilitation guidelines and clinical outcomes within the existing literature. In patients with recurrent ACL graft failures, ACWPTO provides a safe and reliable technique to correct an elevated PTS and return patients back to full activities with reduced risk of ACL graft re-tear.

Risk Factors for New Meniscal Tears following Anterior Cruciate Ligament Reconstruction

2020 ◽  
Author(s):  
Chloe Xiaoyun Chan ◽  
Christian Silas ◽  
Nadia Nastassia Ifran ◽  
Ying Ren Mok ◽  
Lingaraj Krishna
Keyword(s):  
Anterior Cruciate Ligament ◽  
Graft Failure ◽  
Ligament Reconstruction ◽  
Cruciate Ligament ◽  
Meniscal Repair ◽  
Meniscal Tears ◽  
Index Procedure ◽  
Acl Graft ◽  
Meniscal Surgery ◽  
Anterior Cruciate

AbstractThis study aims to compare the rate of meniscal tears after anterior cruciate ligament (ACL) reconstruction in patients who have undergone concomitant meniscal repair during the index procedure with that in patients who have not undergone such surgery. It also evaluates other risk factors, such as age, gender, race, body mass index (BMI), site of concomitant meniscal surgery, and ACL graft failure. This is a retrospective study conducted at a large tertiary public hospital. Patients who underwent primary anterior cruciate ligament reconstruction (ACLR) surgery with or without concomitant meniscal repair from 2011 to 2016 were identified. Patients with old meniscal tears and previous meniscal surgeries were excluded. The aforementioned demographical, injury, and surgical details were obtained and analyzed using univariate and multivariate logistic regression analysis. Our study cohort included 754 patients. Primary ACLR surgery was performed with meniscal repair in 172 (22.8%) of the patients, with meniscectomy in 202 (26.8%) of the patients, and without concomitant meniscal surgery in 380 (50.4%) of the patients. A total of 81 (10.7%) patients developed meniscal tears after the index procedure. Such tears occurred in 12.2% (21 of 172) of the patients who had undergone concomitant meniscal repair during the index ACLR, and in 10.3% (60 of 582) of the patients who had not undergone concomitant meniscal repair (p = 0.30). On multivariate analysis, only ACL graft failure was significantly associated with new meniscal tears (p < 0.001, odds ratio 18.69, 95% confidence interval 9.18–38.05). ACL graft failure is the only independent risk factor for meniscal tears after ACLR surgery in our large cohort of patients. Concomitant meniscal repair was not an associated risk factor.

scholarly journals The Effect of Posterior Tibial Slope on the Risk of Revision Surgery After Anterior Cruciate Ligament Reconstruction

2021 ◽  
pp. 036354652110541
Author(s):  
Lene Dæhlin ◽  
Eivind Inderhaug ◽  
Torbjørn Strand ◽  
Anagha P. Parkar ◽  
Eirik Solheim
Keyword(s):  
Anterior Cruciate Ligament ◽  
Revision Surgery ◽  
Graft Failure ◽  
Cruciate Ligament ◽  
Tibial Slope ◽  
Posterior Tibial Slope ◽  
Graft Size ◽  
Posterior Tibial ◽  
Anterior Cruciate ◽  
Time From Injury

Background: A significant proportion of patients undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) later experience graft failure. Some studies suggest an association between a steep posterior tibial slope (PTS) and graft failure. Purpose: To examine the PTS in a large cohort of patients about to undergo ACLR and to determine whether a steep PTS is associated with later revision surgery. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective review of a cohort undergoing isolated ACLR between 2002 and 2012 (with 8-19 years of follow-up) was conducted. Preoperative sagittal radiographs of knees in full extension were used for measurements of the PTS. There were 2 independent examiners who performed repeated measurements to assess the reliability of the method. Statistical analyses were performed to compare the PTS in the groups with and without later revision surgery. Results: A total of 728 patients, with a mean age of 28 years at the time of surgery, were included. Overall, 10% (n = 76) underwent revision surgery during the observation period. The group of injured knees had a significantly steeper PTS compared with the group of uninjured knees (9.5° vs 8.7°, respectively; P < .05). The mean PTS in the no revision group was 9.5° compared with 9.3° in the revision group (not significant). Dichotomized testing of revision rates related to PTS cutoff values of ≥10°, ≥12°, ≥14°, ≥16°, and ≥18° showed no association of PTS steepness (not significant) to graft failure. Patients with revision were younger than the ones without (mean age, 24 ± 8 vs 29 ± 10 years, respectively) and had a shorter time from injury to ACLR (mean, 14 ± 27 vs 24 ± 44 months, respectively) as well as a smaller graft size (8.2 vs 8.4 mm, respectively; P = .040). Conclusion: The current study did not find any association between a steep PTS measured on lateral knee radiographs and revision ACL surgery. However, a steeper PTS was seen in the group of injured knees compared with the group of uninjured (contralateral) knees. Independent of the PTS, younger patients, those with a shorter time from injury to surgery, and those with a smaller graft size were found to undergo revision surgery more often.

scholarly journals Graft Survivorship After Anterior Cruciate Ligament Reconstruction Based on Tibial Slope

2021 ◽  
pp. 036354652110492
Author(s):  
Clemens Gwinner ◽  
Milan Janosec ◽  
Guido Wierer ◽  
Michael Wagner ◽  
Andreas Weiler
Keyword(s):  
Anterior Cruciate Ligament ◽  
Acl Reconstruction ◽  
Odds Ratio ◽  
Cox Regression ◽  
Cruciate Ligament ◽  
Tibial Slope ◽  
Acl Graft ◽  
Group A ◽  
Anterior Cruciate ◽  
Group B

Background: Increased tibial slope (TS) is believed to be a risk factor for anterior cruciate ligament (ACL) tears. Increased TS may also promote graft insufficiency after ACL reconstruction. Purpose: To delineate the relationship between TS and single as well as multiple graft insufficiencies after ACL reconstruction. Study Design: Cohort study; Level of evidence 3. Methods: We retrospectively identified 519 patients who had sustained ACL graft insufficiency after primary or revision ACL reconstruction (1 graft insufficiency, group A; 2 graft insufficiencies, group B; and ≥3 graft insufficiencies, group C). In addition, a subgroup analysis was conducted in 63 patients who received all surgical interventions by 2 specialized high-volume, single-center ACL surgeons. TS was measured by an observer with >10 years of training using lateral knee radiographs, and intrarater reliability was performed. Multiple logistic and univariate Cox regression was used to assess the contribution of covariates (TS, age, sex, and bilateral ACL injury) on repeated graft insufficiency and graft survival. Results: The study included 347 patients, 119 female and 228 male, who were 24 ± 9 years of age at their first surgery (group A, n = 260; group B, n = 62; group C, n = 25). Mean TS was 9.8°± 2.7° (range, 3°-18°). TS produced the highest adjusted odds ratio (1.73) of all covariates for repeated graft insufficiency. A significant correlation was found between TS and the number of graft insufficiencies ( r = 0.48; P < .0001). TS was significantly lower in group A (9.0°± 2.3°) compared with group B (12.1°± 2.5°; P < .0001) and group C (12.0°± 2.6°; P < .0001). A significant correlation was seen between the TS and age at index ACL tear ( r = −0.12; P = .02) as well as time to graft insufficiency ( r = −0.12; P = .02). A TS ≥12° had an odds ratio of 11.6 for repeated ACL graft insufficiency. Conclusion: The current results indicate that patients with a markedly increased TS were at risk of early and repeated graft insufficiency after ACL reconstruction. Because the TS is rarely accounted for in primary and revision ACLR, isolated soft tissue procedures only incompletely address recurrent graft insufficiency in this subset of patients.

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