Magnetic Resonance Imaging Evaluation of the Anterolateral Ligament and the Iliotibial Band in Acute Anterior Cruciate Ligament Injuries Associated With Segond Fractures.

PURPOSE: To evaluate the magnetic resonance imaging (MRI) characteristics of Segond fractures, including the structures attached to the avulsed fragment, the integrity of anterolateral ligament (ALL) and iliotibial band (ITB), and fragment size and location. METHODS: This was a retrospective, cross-sectional study with MRI scans from 2016 to 2019 with the term "Segond" in the reports, signs of acute trauma, and a bony anterolateral tibial avulsion (Segond) fracture. Two experienced observers accessed images to evaluate fragment dimensions (anteroposterior, mediolateral, and craniocaudal) and distances from anatomic landmarks (Gerdy's tubercle, articular surface, and posterolateral tibial corner). ALLs and ITBs also were evaluated, both for integrity and for attachment to the avulsed bony fragment. Data were statistically evaluated for significant correlations. RESULTS: Forty-eight knee MRIs of patients suffering from a combined anterior cruciate ligament and Segond injury were evaluated. The ALL presented with edema in 28 cases (58.3%) and was torn in 3 cases (6.3%). The ALL was attached to the bone fragment in all cases and the ITB also was attached in 25 cases (52.1%). Receiver operating characteristic curves also demonstrated that the larger each of the dimensions and the volume of the fragment, the greater the probability of ITB fibers being inserted. Also, the narrower the distance from the fragment to the center of Gerdy's tubercle, the greater the probability of iliotibial band fibers being attached. Interobserver correlation varied from 0.87 to 0.97 for all measurements. CONCLUSIONS: In all combined ACL injuries and Segond fracture MRI cases, the complete ALL inserted on the avulsed bony fragment, whereas the posterior part of the ITB was only attached in 52.1% of the cases. Segond fracture fragment size was predictive for the structures attached to it. The ALL was abnormal in 64.5% of cases and presented a clear discontinuity in 6.3%. LEVEL OF EVIDENCE: Case Series, Level IV.

Structural allograft impaction enables fast rehabilitation in opening-wedge high tibial osteotomy: a consecutive case series with one year follow-up.

PURPOSE: Painful and slow recovery are the presumed disadvantages after opening-wedge high tibial osteotomy (HTO) and play a role in favouring arthroplasty as treatment for moderate isolated medial knee arthritis. The primary study objective was to investigate the effect of press-fit structural impacted bone allograft with locking plate fixation on early ambulation, postoperative pain levels, and resumption of daily-life activities in opening-wedge HTO. METHODS: A prospective consecutive opening-wedge HTO case series was conducted, including 103 patients with final follow-up at 1 year. Weight-bearing was allowed from the day after surgery "as tolerated" by the patient. Clinical assessment included the Numeric Rating Scale (NRS), Knee injury and Osteoarthritis Outcome Score (KOOS), and Lysholm score. Additionally, the Knee Society Score (KSS) was assessed during consultation at 1, 3, and 12 months postoperatively with special attention for clinical anchor questions. Required sample size was calculated and a linear mixed-effect model was used for repeated measures over time of the clinical scores. RESULTS: The NRS decreased by 1.5 at 1 month (p < 0.01) and 2.1 at 3 months (p < 0.01), while KOOS pain significantly improved with 19.2 (p < 0.01) by this time compared to baseline. Under reduced pain levels, 98% were able to walk > 500 m without support, while all patients were able to climb up and down the stairs 3 months postoperatively. CONCLUSION: The study strongly supports the initial hypothesis that applying structural triangular bone allograft in HTO leads to low postoperative pain levels, early ambulation, and excellent short-term clinical outcomes. Study results have the potential to alter the general perception about HTO being a painful procedure with painstakingly slow recovery and consequently encourage the consideration of HTO as a highly valuable joint-preserving option, while treating unicompartmental knee arthritis. LEVEL OF EVIDENCE: IV (case series).

High prevalence of anterolateral ligament abnormalities in magnetic resonance images of anterior cruciate ligament-injured knees.

The purpose of this study was to identify the newly described anterolateral ligament of the human knee on magnetic resonance imaging and to describe its eventual radiological abnormalities in anterior cruciate ligament-injured subjects. A retrospective cohort study on a series of consecutive subjects undergoing anterior cruciate ligament reconstructive surgery was performed. The MR images of 206 included knees were studied and the status of the anterolateral ligament status was judged to be either "non-visualized", "normal" or "abnormal". Of all the visualized anterolateral ligaments, 44 (21.3%) were considered uninjured, while 162 (78.8%) knees demonstrated radiological ALL abnormalities. The majority of ALL abnormalities were situated in the distal part of the ligament (77.8%). In conclusion, the anterolateral ligament can be identified on classic knee magnetic resonance images. Although anterior cruciate ligament injured subjects often demonstrated associated anterolateral ligament lesions, further research is needed in order to establish the clinical relevance of these highly frequent radiological abnormalities.

Clinical and radiological outcomes of medial opening-wedge monoplanar and biplanar high tibial osteotomy using a triangular allograft impaction technique: A retrospective single centre study.

PURPOSE: The aim of the study was to research the clinical and radiological outcomes between monoplanar and biplanar medial opening-wedge high tibial osteotomy. We hypothesized that there would be no differences between both techniques when using a triangular allograft impaction technique. METHODS: A single-centre, observational, retrospective study was conducted on 103 opening-wedge high tibial osteotomy patients from January 2017 to September 2019. Data collection, NRS and KOOS-PS, was performed preoperatively, 3 months and 12 months postoperatively. Radiological assessment (Kellgren-Lawrence, mechanical femoral-tibial angle, posterior tibial slope angle, lateral patellar tilt, patellar height) was performed on standing radiographs. RESULTS: In total 32 patients were included in the biplanar group and 71 patients in the monoplanar group. NRS and KOOS-PS scores improved significantly (p < 0.001) in time for both groups from baseline to 3 m PO and further to 1 year postoperatively. Our results showed no differences in radiological outcomes such as patellar height, LPT and posterior tibial slope angle. The monoplanar group did have more Takeuchi I and III fractures and a higher mFTA angle without clinical repercussion. CONCLUSIONS: Using a triangular allograft impaction technique for monoplanar and biplanar medial opening-wedge high tibial osteotomy gives no differences in clinical (NRS and KOOS) and radiological outcomes. Although a difference in Takeuchi fractures was found for monoplanar patients, no additional fixation was necessary, nor did clinical complications occur. We can conclude that triangular allograft impaction technique creates a stable construct and standardizes the healing procedure postoperatively for both monoplanar and biplanar medial opening-wedge high tibial osteotomy.

Impacted bone allograft personalised by a novel 3D printed customization kit produces high surgical accuracy in medial opening wedge high tibial osteotomy: a pilot study.

PURPOSE: Contemporary medial opening wedge high tibial osteotomy (MOWHTO) still seems to struggle with inconsistent accuracy outcomes. Our objective was to assess surgical accuracy and short-term clinical outcomes when using 3D planning and a patient-specific instrumentation (PSI) kit to prepare customized bone allografts. METHODS: Thirty subjects (age 48y ± 13) were included in a double-center prospective case series. A low-dose CT-scan was performed to generate 3D bone models, a MOWHTO was simulated, and PSI was designed and 3D printed based on the complementary negative of the planned osteotomy gap. Clinical outcome was assessed at two, four, 12 weeks and one year using NRS, KOOS, UCLA activity score, EQ-5D and anchor questions. A linear-mixed model approach was implemented for data analysis. RESULTS: Preoperative 3D values were 175.0° ± 2.2 mechanical tibiofemoral angle (mTFA), 85.0° ± 3.0 medial proximal tibial angle (MPTA), and 94.1° ± 3.4 medial posterior tibial slope (MPTS). Target planning ranged from slight varus to the lateral tibial spine (slight valgus). Postoperative 3D analysis showed an accuracy of 1.1° ± 0.7 ΔMPTA (p = 0.04) and 1.2° ± 1.2 ΔMPTS (p = 0.11). NRS decreased from baseline 6.1 ± 1.9 to 2.7 ± 1.9 at four weeks (p < 0.001) and 1.7 ± 1.9 at one year (p < 0.001). KOOS increased from 31.4 ± 17.6 to 50.6 ± 20.6 at 12 weeks (p < 0.001) and to 71.8 ± 15.6 at one year (p < 0.001). CONCLUSION: The study suggests that 3D printed instrumentation to personalize structural bone allograft is a viable alternative method in MOWHTO that has the benefit of optimizing surgical accuracy while providing early and consistent pain relief after surgery.

Changes in knee joint line orientation after high tibial osteotomy are the result of adaptation of the lower limb to the new alignment.

BACKGROUND: Changes in knee joint line orientation (KJLO) resulting in excessive joint line obliquity are a well-known consequence of high tibial osteotomy (HTO) procedures and could lead to degenerative changes. The precise effect of the correction on final KJLO changes is poorly understood. The goal of this study was to identify radiographical parameters that could help to explain the size of KJLO changes after HTO surgery. METHODS: A total 117 HTO patients were radiographically examined preoperatively and three months postoperatively. Radiographic parameters were KJLO, medial proximal tibial angle (MPTA), hip-knee angle (HKA), mechanical lateral distal femoral angle (mLDFA), lateral distal tibial angle (LDTA), knee joint line congruence angle (KJLCA), ankle joint line congruence angle (AJLCA) and ankle joint line orientation (AJLO). Four new radiographic parameters were introduced to describe knee and foot position on long-leg X-ray: malleolar distance to midline (MDTM), intermalleolar distance (IMD), condylar distance to midline (CDTM) and intercondylar distance (ICD). Correlations of these parameters and changes in KJLO were assessed. RESULTS: Strong correlations are found between KJLO changes and MDTM (r = 0.709), IMD (r = 0.691), CDTM (r = 0.711) and ICDM (r = 0.702), in contrast to weak correlations between changes in KJLO and MPTA (r = -0.342). These results suggest an important impact of foot and knee position changes on the final alteration of KJLO after HTO. CONCLUSIONS: The final change of KJLO after HTO is the effect of adaptation of the lower limb, which is driven by the (maximum) alterations of foot and knee position rather than the size of correction of the procedure.