High-Grade Posterolateral Tibial Plateau Impaction Fractures in the Setting of a Primary Anterior Cruciate Ligament Tear Are Correlated With an Increased Preoperative Pivot Shift and Inferior Postoperative Outcomes After Anterior Cruciate Ligament Reconstruction

2020 ◽  
Vol 48 (9) ◽  
pp. 2185-2194
Author(s):  
David L. Bernholt ◽  
Grant J. Dornan ◽  
Nicholas N. DePhillipo ◽  
Zachary S. Aman ◽  
Mitchell I. Kennedy ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Anterior Cruciate Ligament ◽  
Bone Loss ◽  
Tibial Plateau ◽  
Pivot Shift ◽  
Cruciate Ligament ◽  
Pearson Correlation ◽  
High Grade ◽  
Mri Scans ◽  
Anterior Cruciate

Background: Impaction fractures of the posterolateral tibial plateau have been previously described to occur in association with anterior cruciate ligament (ACL) tears; however, the effect of these injuries on patient-reported outcomes (PROs) after ACL reconstruction (ACLR) is not well known. Purpose: (1) To assess the effect of posterolateral tibial plateau impaction fractures on preoperative clinical knee stability assessed by the Lachman and pivot-shift examinations and (2) to assess the effect of impaction fractures on PROs after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing ACLR for primary ACL tears with available magnetic resonance imaging (MRI) scans were included in this study. MRI scans were reviewed for the presence of posterolateral tibial plateau impaction fractures, which were classified according to the morphological variant. Associations with clinical laxity determined by an examination under anesthesia were assessed using binary logistic regression. Also, 2-year postoperative PROs (12-Item Short Form Health Survey [SF-12] Mental Component Scale and Physical Component Scale [PCS], Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Tegner scores) were modeled using multiple ordinal logistic regression to assess the effect of posterolateral tibial plateau impaction fracture classification while adjusting for other covariates. Pearson correlation coefficients (PCCs) were used to assess for correlations between postoperative PROs and the amount of tibial plateau bone loss present. Results: Displaced posterolateral tibial plateau impaction fractures were present in 407 (49.3%) of 825 total knees included in this study. Knees with type IIIB impaction fractures had an increased likelihood of having a high-grade pivot shift (odds ratio, 2.3; P = .047), with no other impaction fracture types showing a significant association. There were no significant associations between posterolateral tibial plateau impaction fracture type and a higher Lachman grade. Of the 599 eligible knees with 2-year follow-up, postoperative information was obtained for 419 (70.0%). Patients improved in all PROs at a mean of 3.0 years after ACLR ( P < .001). Multiple ordinal logistic regression demonstrated a posterolateral tibial plateau impaction fracture as an independent predictor of the postoperative Lysholm score, with higher grade impaction fractures showing decreased Lysholm scores. Pearson correlation testing demonstrated weak but statistically significant correlations between sagittal bone loss of posterolateral tibial plateau impaction fractures and SF-12 PCS (PCC = –0.156; P = .023), WOMAC total (PCC = 0.159; P = .02), Lysholm (PCC = –0.203; P = .003), and Tegner scores (PCC = –0.151; P = .032). Conclusion: When classified into distinct morphological subtypes, high-grade posterolateral tibial plateau impaction fractures were independently associated with decreased postoperative outcomes after ACLR when controlling for other demographic or clinical variables. Patients with large depression-type posterolateral tibial plateau impaction fractures (type IIIB) had an increased likelihood of having high-grade pivot-shift laxity on clinical examination under anesthesia.

scholarly journals Tibial slope in the posterolateral quadrant with and without ACL injury

2021 ◽  
Author(s):  
A. Korthaus ◽  
M. Krause ◽  
G. Pagenstert ◽  
M. Warncke ◽  
F. Brembach ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Risk Factor ◽  
Knee Joint ◽  
Tibial Plateau ◽  
Cruciate Ligament ◽  
Acl Injury ◽  
Tibial Slope ◽  
Mri Scans ◽  
The Mean ◽  
Anterior Cruciate

Abstract Introduction An increased tibial slope is a risk factor for rupture of the anterior cruciate ligament. In addition, a tibial bone bruise or posterior lateral impression associated with slope changes also poses chronic ligamentous instability of the knee joint associated with an anterior cruciate ligament (ACL) injury. In the majority of cases, the slope is measured in one plane X-ray in the lateral view. However, this does not sufficient represent the complex anatomy of the tibial plateau and especially for the posterolateral quadrant. Normal values from a “healthy” population are necessary to understand if stability of the knee joint is negatively affected by an increasing slope in the posterolateral area. Until now there are no data about the physiological slope in the posterolateral quadrant of the tibial plateau. Materials and methods In 116 MRI scans of patients without ligamentous lesions and 116 MRI scans with an ACL rupture, tibial slope was retrospectively determined using the method described by Hudek et al. Measurements were made in the postero-latero-lateral (PLL) and postero-latero-central (PLC) segments using the 10-segment classification. In both segments, the osseous as well as the cartilaginous slope was measured. Measurements were performed by two independent surgeons. Results In the group without ligamentous injury the mean bony PLL slope was 5.8° ± 4.8° and the cartilaginous PLL slope was 6.7° ± 4.8°. In the PLC segment the mean bony slope was 6.6° ± 5.0° and the cartilaginous slope was 9.4° ± 5.7°. In the cohort with ACL rupture, the bony and cartilaginous slope in both PLL and PCL were significantly higher (P < 0.001) than in the group without ACL injury (bony PLL 9.8° ± 4.8°, cartilage PLL 10.4° ± 4.7°, bony PLC 10.3° ± 4.8°, cartilage PLL 12.8° ± 4.3°). Measurements were performed independently by two experienced surgeons. There were good inter- (CI 87–98.7%) and good intraobserver (CI 85.8–99.6%) reliability. Conclusion The bony and the cartilaginous slope in the posterolateral quadrant of the tibial plateau are different but not independent. Patients with an anterior cruciate ligament injury have a significantly steeper slope in the posterolateral quadrant compared to a healthy group. Our data indicate that this anatomic feature might be a risk factor for a primary ACL injury which has not been described yet. Level of evidence III.

Evaluation of Anterolateral Ligament Healing After Anatomic Anterior Cruciate Ligament Reconstruction

2020 ◽  
Vol 48 (5) ◽  
pp. 1078-1087 ◽  
Author(s):  
Dhong Won Lee ◽  
Jin Goo Kim ◽  
Hyun Tae Kim ◽  
Seung Ik Cho
Keyword(s):  
Tibial Plateau ◽  
Pivot Shift ◽  
Cruciate Ligament ◽  
Acl Rupture ◽  
High Grade ◽  
Concomitant Lesions ◽  
Anterior Cruciate ◽  
Healing Group ◽  
Bone Contusions

Background: Few studies have reported the healing process of anterolateral ligament (ALL) injuries. Purpose/Hypothesis: This study investigated the healing status of ALL injuries after primary anterior cruciate ligament (ACL) reconstruction (ACLR). Additionally, we investigated the association between the healing status of ALL injuries and associated lesions such as osseous lesions and meniscal tears occurring at the time of an ACL rupture. We hypothesized that acute ALL injuries show a high rate (more than two-thirds) of healing at the 1-year follow-up after ACLR and that concomitant lesions observed at the time of an ACL rupture affect the healing status of the ALL. Study Design: Case-control study; Level of evidence, 3. Methods: We retrospectively investigated patients with ALL injuries who underwent primary ACLR between March 2015 and February 2017. Using magnetic resonance imaging (MRI), we evaluated the features of ALL injuries and concomitant lesions, and MRI was performed at the 1-year follow-up to assess the healing status of the ALL. We investigated the association between the healing status of the ALL and concomitant lesions observed at the time of an ACL rupture. A subjective assessment was performed using the Lysholm score, International Knee Documentation Committee subjective score, and Tegner activity scale. Objective tests included an isokinetic strength assessment and functional performance testing. Results: With respect to the severity of ALL injuries, of 54 patients, a complete rupture occurred in 16 (29.6%) of the 54 patients and a partial rupture in 38 (70%). A significant association was observed between the severity of ALL injuries and bone contusions (lateral tibial plateau and medial tibial plateau [MTP]) and meniscus ramp lesions (Fisher exact test: P = .023, .012, and .023, respectively). Good and partial healing of the ALL occurred in 16 (29.6%) and 23 (42.6%) of 54 patients, respectively. Scar formation occurred in 12 (22.2%), and nonvisualization of the ALL was observed in 3 (5.6%) of 54 patients. Poor healing of the ALL was associated with preoperative MTP bone contusions and a high-grade pivot shift. Multivariate analysis showed that an MTP bone contusion was an independent risk factor associated with poor healing of the ALL. Among the functional tests performed, significant differences were observed between the good and poor healing groups with respect to the carioca test ( P = .039). The good healing group (n = 16) showed a negative pivot shift at the last follow-up, whereas 5 (13.2%) of the patients from the poor healing group (n = 38) showed a positive pivot shift, including 2 (5.3%) with a high-grade pivot shift. Conclusion: Approximately 70% of acute ALL injuries showed poor healing at the 1-year follow-up. Poor healing of ALL injuries was significantly associated with preoperative MTP bone contusions and a high-grade pivot shift. Therefore, a careful assessment of posteromedial bone contusions at the time of an ACL rupture is warranted, particularly in patients with a high-grade pivot shift.

scholarly journals Distribution of Bone Contusion Patterns in Acute Noncontact Anterior Cruciate Ligament–Torn Knees

2021 ◽  
Vol 49 (2) ◽  
pp. 404-409
Author(s):  
Sophia Y. Kim-Wang ◽  
Melissa B. Scribani ◽  
Michael B. Whiteside ◽  
Louis E. DeFrate ◽  
Tally E. Lassiter ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Tibial Plateau ◽  
Femoral Condyle ◽  
Cruciate Ligament ◽  
Acl Injury ◽  
Meniscal Tears ◽  
Mri Scans ◽  
Anterior Cruciate ◽  
Operative Notes ◽  
Bone Contusions

Background: Bone contusions are commonly observed on magnetic resonance imaging (MRI) in individuals who have sustained a noncontact anterior cruciate ligament (ACL) injury. Time from injury to image acquisition affects the ability to visualize these bone contusions, as contusions resolve with time. Purpose: To quantify the number of bone contusions and their locations (lateral tibial plateau [LTP], lateral femoral condyle [LFC], medial tibial plateau [MTP], and medial femoral condyle [MFC]) observed on MRI scans of noncontact ACL-injured knees acquired within 6 weeks of injury. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We retrospectively reviewed clinic notes, operative notes, and imaging of 136 patients undergoing ACL reconstruction. The following exclusion criteria were applied: MRI scans acquired beyond 6 weeks after injury, contact ACL injury, and previous knee trauma. Fat-suppressed fast spin-echo T2-weighted MRI scans were reviewed by a blinded musculoskeletal radiologist. The number of contusions and their locations (LTP, LFC, MTP, and MFC) were recorded. Results: Contusions were observed in 135 of 136 patients. Eight patients (6%) had 1 contusion, 39 (29%) had 2, 41 (30%) had 3, and 47 (35%) had 4. The most common contusion patterns within each of these groups were 6 (75%) with LTP for 1 contusion, 29 (74%) with LTP/LFC for 2 contusions, 33 (80%) with LTP/LFC/MTP for 3 contusions, and 47 (100%) with LTP/LFC/MTP/MFC for 4 contusions. No sex differences were detected in contusion frequency in the 4 locations ( P > .05). Among the participants, 50 (37%) had medial meniscal tears and 52 (38%) had lateral meniscal tears. Conclusion: The most common contusion patterns observed were 4 locations (LTP/LFC/MTP/MFC) and 3 locations (LTP/LFC/MTP).

Ramp Lesion Subtypes: Prevalence, Imaging, and Arthroscopic Findings in 2156 Anterior Cruciate Ligament Reconstructions

2021 ◽  
pp. 036354652110061
Author(s):  
Mathieu Thaunat ◽  
Pramod Ingale ◽  
Alexandre Penet ◽  
Samih Kacem ◽  
Ibrahim Haidar ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Pivot Shift ◽  
Cruciate Ligament ◽  
Lesion Type ◽  
Ramp Lesion ◽  
Mri Scans ◽  
Anterior Cruciate ◽  
Type 3

Background: Ramp lesions are defined as a particular type of injury within the posterior horn of the medial meniscus and its meniscocapsular attachments. Five subtypes have been described: type 1, meniscocapsular lesion; type 2, partial superior lesion; type 3, partial inferior lesion or hidden type; type 4, complete tear in the red zone; and type 5, complete double tear. Purpose: (1) To determine the prevalence of different subtypes of ramp lesions in patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR). (2) To describe the characteristics of ramp lesions based on imaging and diagnostic arthroscopy. Study Design: Cross-sectional study; Level of evidence, 3. Methods: All patients who underwent arthroscopic ACLRs between November 2015 and November 2018 by 2 senior surgeons at 1 institution were evaluated retrospectively (1) to describe the subtypes of ramp lesions diagnosed intraoperatively using transnotch arthroscopic exploration of the posteromedial compartment and (2) to look for any factors significantly associated with these subtypes. The following parameters were studied: demographics; history and clinical findings including time between injury and surgery, side-to-side laxity, and pivot shift; lesions missed on magnetic resonance imaging (MRI) scans and medial proximal tibial bone contusion visible on MRI scans; and arthroscopic confirmation of ramp lesion (ie, prevalence), associated lateral meniscal tear, or medial chondral tear. Results: Out of 2156 primary or revision arthroscopic reconstructions, 334 ramp lesions were confirmed, giving a prevalence of 15.5%. The subtype distribution was as follows: type 1, 47.9%; type 2, 4.8%; type 3, 11.4%; type 4, 28.7%; type 5, 7.2%. Multivariate analysis showed that gross pivot shift was significantly associated with complete ramp tears (odds ratio, 4.8; 95% CI, 1.7-17.2). Hidden lesions (type 3, inferior partial tear in the red zone) were the most likely to be missed on preoperative MRI (45.9%). Conclusion: In a population undergoing ACLR, the prevalence of ramp lesions was 15.5%. Among the subtypes of ramp lesion, the most common was a meniscocapsular junction tear (type 1). Partial inferior tears (type 3) were the most likely to be missed on preoperative MRI scans. Gross pivot shift was significantly associated with complete ramp tears (types 1, 4, and 5).

Anterolateral Ligament Reconstruction Improves Anteroposterior Stability As Well As Rotational Stability in Revision Anterior Cruciate Ligament Reconstruction with High-Grade Pivot Shift

2020 ◽  
Author(s):  
Kyoung Ho Yoon ◽  
In Uk Hwang ◽  
Eung Ju Kim ◽  
Yoo Beom Kwon ◽  
Sang-Gyun Kim
Keyword(s):  
Anterior Cruciate Ligament ◽  
Ligament Reconstruction ◽  
Pivot Shift ◽  
Cruciate Ligament ◽  
Anterolateral Ligament ◽  
Rotational Stability ◽  
High Grade ◽  
Cruciate Ligament Reconstruction ◽  
Anterior Cruciate

AbstractThis study aimed to investigate the effect of anterolateral ligament reconstruction (ALLR) in revision anterior cruciate ligament reconstruction (ACLR) with high-grade pivot shift. The hypothesis was that revision ACLR combined with ALLR (RACLR with ALLR group) would show superior clinical outcomes to those of isolated revision ACLR. We retrospectively evaluated consecutive patients who underwent revision ACLR (RACLR) combined with ALLR between October 2015 and January 2017. The indication for combination of ALLR with revision ACLR was failed ACLR with ≥G2 pivot-shift instability. The control group included patients who underwent isolated revision ACLR (isolated RACLR group) for the same indication between July 2013 and September 2015. Exclusion criteria were ≤G1 pivot-shift instability, multiple ligament reconstruction, bilateral ligament injury, double-bundle reconstruction, insufficient medical records, postoperative infection, and follow-up loss at postoperative 2 years. Clinical scores, stability tests, and failure rates were compared between groups at the 2-year follow-up. The RACLR with ALLR group had 18 patients (mean age, 32.9 ± 10.8 years) and the RACLR group had 21 patients (mean age, 29.6 ± 10.2 years). Clinical scores at the 2-year follow-up showed no significant differences between groups. However, the RACLR with ALLR group showed better stability in the Lachman test (p = 0.005), pivot-shift test (p = 0.030), and side-to-side difference in stress radiographs (3.9 ± 3.0 mm vs. 5.9 ± 2.8 mm, p = 0.018) than the isolated RACLR group. The RACLR with ALLR group had two failures (11.1%), and the RACLR group had three failures (14.3%). In conclusion, ALLR in revision ACLR with high-grade pivot shift improves anteroposterior stability as well as rotational stability at 2-year follow-up. Therefore, ALLR is recommended with revision ACLR, especially in patients with high-grade pivot shift. This is a Level III, retrospective cohort review.

scholarly journals Incidence of Displaced Posterolateral Tibial Plateau and Lateral Femoral Condyle Impaction Fractures in the Setting of Primary Anterior Cruciate Ligament Tear

2020 ◽  
Vol 48 (3) ◽  
pp. 545-553 ◽  
Author(s):  
David L. Bernholt ◽  
Nicholas N. DePhillipo ◽  
Matthew D. Crawford ◽  
Zachary S. Aman ◽  
W. Jeffrey Grantham ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Tibial Plateau ◽  
Femoral Condyle ◽  
Cruciate Ligament ◽  
Lateral Meniscus ◽  
Lateral Femoral Condyle ◽  
Lateral Tibial Plateau ◽  
Bone Bruising ◽  
Mri Scans ◽  
Anterior Cruciate

Background: Bone bruising of the posterolateral tibial plateau and the lateral femoral condyle sulcus terminalis has a well-established association with anterior cruciate ligament (ACL) tears. Impaction fractures of the femur and tibia may occur in these locations; however, there is a paucity of literature describing these fractures. Purpose: The primary objective was to quantify the incidence, size, and location of impaction fractures of the posterolateral tibial plateau and lateral femoral condyle in patients with primary ACL tears. The secondary objective was to investigate the association between impaction fractures and concomitant meniscal and ligamentous injuries. Study Design: Case series; Level of evidence 4. Methods: Patients with available magnetic resonance imaging (MRI) scans who were treated for primary ACL tear by a single surgeon were identified. MRI scans were reviewed with denotation of posterolateral tibial and femoral condylar contusions and displaced impaction fractures. Measurements of the lateral tibial plateau were taken in all patients with displaced lateral tibial plateau fractures and in a subset of control patients without tibial plateau fracture present to characterize the size and location of the bony lesion. Associations of impaction fractures with concomitant meniscal or ligamentous injuries were evaluated through use of chi-square testing. Results: There were 825 knees identified with available MRI scans. Lateral tibial plateau bone bruising was present in 634 knees (76.8%), and lateral femoral condyle bone bruising was present in 407 knees (49.3%). Posterolateral tibial plateau impaction fractures were present in 407 knees (49.3%), and lateral femoral condylar impaction fractures were present in 214 knees (25.9%). Patients with posterolateral tibial plateau impaction fractures were older than patients without these fractures (42.6 vs 32.7 years; P < .001), whereas patients with lateral femoral condylar impaction fractures were younger (23.8 vs 32.7 years; P < .001). There were 71 knees (8.6%) with a posterolateral tibial plateau impaction fracture with greater than 10% loss of lateral tibial plateau depth, and this group had an increased incidence of lateral meniscus posterior root tears (22.1% vs 12.0%; P = .02). Conclusion: Posterolateral tibial plateau impaction fractures occurred with a high incidence (49.3%) in patients with primary ACL tears and demonstrated an increased association with lateral meniscus posterior horn root tears as their size increased. Lateral femoral condylar impaction fractures occurred in 25.9% of patients with primary ACL tears and entailed an increased incidence of lateral meniscal tears and medial meniscal ramp lesions.

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