Trochlear Dysplasia Is Associated With Increased Sagittal Tibial Tubercle Trochlear-Groove Distance in Patients With Patellar Instability.

PURPOSE: To compare the sagittal position of the tibial tubercle in relation the trochlea groove in patients with and without trochlear dysplasia (TD). Patients with high-grade TD show a significantly increased sagittal position of the tibial tubercle in relation to the trochlear groove (sTTTG) compared with patients without TD. This may affect patellofemoral loading and contribute to the increased prevalence of cartilage lesions seen in the patellofemoral joint of patients with dysplasia of the trochlear groove. METHODS: All patients between January 2017 and December 2020 with high-grade TD (Dejour type B, C, and D) who underwent patellar-stabilizing surgery for patellar instability at a single institution were included in the current study. Patients without preoperative magnetic resonance imaging (MRI), any previous osteotomy on the affected lower extremity, or cruciate ligament insufficiency were excluded. Patients who underwent knee arthroscopy for meniscal repair/debridement without any signs of TD or any of the aforementioned criteria served as the control group. Preoperative MRI was retrospectively assessed to compare common patellofemoral anatomic parameters including patellar angle, patellar tilt, patella morphology according to Wiberg, Caton-Deschamps index, PF index, trochlear sulcus angle, sulcus depth, lateral inclination angle of the trochlea, tibiofemoral rotation, TTTG, and sTTTG distance between both groups. The sTTTG is measured as the distance between the nadir point of the cartilaginous trochlear groove and the most anterior point of the tibial tubercle on an axial MRI. Independent predictors for the sTTTG were assessed for patients with TD. RESULTS: Patients with high-grade TD (n = 82) showed an increased patellar tilt, Caton-Deschamps index, trochlear sulcus angle, lateral tibiofemoral rotation angle, TTTG, and sTTTG (9.16 ± 4.47 mm vs 2.66 ± 4.21 mm) compared with the control group (n = 83) (P < .001). Patellar angle, PF index, sulcus depth, and lateral inclination angle of the trochlear were significantly decreased in the TD group (P < .001). The sTTTG was similar in all TD groups (n.s.). Among patients with TD, both tibiofemoral rotation and patellar height were independent predictors of the sTTTG (P < .05). CONCLUSIONS: Patients with high-grade TD show not only abnormal values in common patellofemoral instability risk factors but also a significantly increased sTTTG compared with patients without TD. LEVEL OF EVIDENCE: Level III, retrospective case comparative study.

No significant change of tibiofemoral rotation after femoral rotational osteotomy in patients with patellofemoral instability.

PURPOSE: An increased value of tibiofemoral rotation is frequently observed in patients with patellofemoral instability or maltracking. Nevertheless, the appropriate approach for addressing this parameter remains unclear so far. One potential approach for correcting tibiofemoral rotation is femoral rotational osteotomy. We hypothesized that femoral rotational osteotomy affects tibiofemoral rotation. METHODS: All patients who underwent femoral rotational osteotomy between January 2018 and May 2022 were included in this study. Pre- and postoperative tibiofemoral rotation and the degree of femoral rotation were measured using two-dimensional (2D) and three-dimensional (3D) measurements. The effect of femoral rotation on tibiofemoral rotation was assessed. RESULTS: Forty knees (18 right and 22 left) of 36 patients (28 females and 8 males) were included. Mean preoperative femoral torsion was 32.1 ± 10.1° in 2D and 30.8 ± 10.1° in 3D. Femoral rotation was performed by -14.1 ± 8.3° using 2D measurements and -15.0 ± 8.0° using 3D measurements. Tibiofemoral rotation changed from 9.9 ± 6.2° to 9.7 ± 6.0° (p = n.s.) in 2D, and from 10.2 ± 5.5° to 9.4 ± 5.4° (p = n.s.) in 3D. CONCLUSION: Tibiofemoral rotation showed no significant changes after femoral rotational osteotomy. Hence, femoral rotational osteotomy cannot be used to correct tibiofemoral rotation in addition to correcting the femoral version. Other surgical techniques need to be evaluated if correction of tibiofemoral rotation is required. LEVEL OF EVIDENCE: Level III.

Increased tibial tuberosity torsion has the greatest predictive value in patients with patellofemoral instability compared to other commonly assessed parameters.

PURPOSE: The multifactorial nature of patellofemoral instability requires a comprehensive assessment of the affected patients. While an association between tibial tuberosity (TT) torsion and patellofemoral instability is known, its specific effect has not yet been investigated. This study investigated the effect of TT torsion on patellofemoral instability. METHODS: This retrospective cohort study compared patients who underwent surgical intervention for patellofemoral instability and asymptomatic controls. TT torsion was measured in addition to other commonly assessed risk factors for patellofemoral instability using standardised computed tomography (CT) data of the lower extremities. The diagnostic performances of the assessed parameters were evaluated using receiver operating characteristic curve analysis and odds ratios (ORs) were calculated. RESULTS: The patellofemoral instability group consisted of 79 knees, compared to 72 knees in the asymptomatic control group. Both groups differed significantly in all assessed parameters (p < 0.001), except for tibial torsion (n.s.). Among all parameters, TT torsion presented the best diagnostic performance for predicting patellar instability with an area under the curve of 0.95 (95% confidence interval [CI], 0.91-0.98; p < 0.001). A cut-off value of 17.7° yielded a 0.87 sensitivity and 0.89 specificity to predict patellar instability (OR, 55.2; 95% CI, 20.5-148.6; p < 0.001). CONCLUSION: Among the evaluated risk factors, TT torsion had the highest predictive value for patellofemoral instability. Patients with TT torsions ≥ 17.7° showed a 55-fold increased probability of patellofemoral instability. Therefore, TT torsion should be included in the assessment of patients with patellofemoral instability. LEVEL OF EVIDENCE: Level III.

Greater hip internal rotation range of motion is associated with increased dynamic knee valgus during jump landing, both before and after fatigue.

PURPOSE: The aim of this study was to analyse sex-specific differences contributing to dynamic valgus in competitive soccer players before and after a standardised fatiguing protocol. METHODS: Thirty-nine healthy female and male competitive soccer players (19 females and 20 males) were recruited for the purpose of this study. Bilateral medial knee displacement (MKD) was assessed during drop jump landings using a three-dimensional motion capture system before and after a standardised fatiguing protocol. In addition, all soccer players underwent clinical examinations, including rotational hip range of motion (ROM), isokinetic strength testing and magnetic resonance imaging (MRI) of the hip and knee. Sex-specific and fatigue-dependent differences were reported, and the influence of demographic, clinical and radiographic factors on MKD was analysed via multiple linear regression models. RESULTS: Compared with male soccer players, female soccer players demonstrated a tendency towards increased MKD during drop jump landings before (p = 0.09) and after the fatiguing protocol (p = 0.04). Sex-specific differences included increased hip internal rotation (IR) ROM, decreased hip external rotation (ER) strength and increased femoral torsion in females (all p < 0.002). According to the multiple linear regression models (stepwise method), increased hip IR ROM (90° of flexion) and the non-dominant leg remained the sole independent predictors of increased MKD during drop jump landings before (p < 0.01 and p = 0.02, respectively) and after fatigue (p < 0.01 and p < 0.01, respectively). An increase in hip IR ROM in females was linearly related to MKD after fatigue (R2 = 0.25; p < 0.01). CONCLUSION: Female soccer players exhibited increased dynamic valgus before and after fatigue, which is likely attributed to joint mobility, as well as muscular and anatomical differences, such as increased hip IR ROM, reduced hip ER strength and increased femoral torsion. In particular, females with increased hip IR ROM were more susceptible to effects of fatigue on MKD, which may increase their risk for anterior cruciate ligament injury. LEVEL OF EVIDENCE: Level III.

The influence of the weight-bearing state on three-dimensional (3D) planning in lower extremity realignment - analysis of novel vs. state-of-the-art planning approaches.

BACKGROUND: The use of 3D planning to guide corrective osteotomies of the lower extremity is increasing in clinical practice. The use of computer-tomography (CT) data acquired in supine position neglects the weight-bearing (WB) state and the gold standard in 3D planning involves the manual adaption of the surgical plan after considering the WB state in long-leg radiographs (LLR). However, this process is subjective and dependent on the surgeons experience. A more standardized and automated method could reduce variability and decrease costs. PURPOSE: The aim of the study was (1) to compare three different three-dimensional (3D) planning modalities for medial open-wedge high tibial osteotomy (MOWHTO) and (2) to describe the current practice of adapting NWB CT data after considering the WB state in LLR. The purpose of this study is to validate a new, standardized approach to include the WB state into the 3D planning and to compare this method against the current gold standard of 3D planning. Our hypothesis is that the correction is comparable to the gold standard, but shows less variability due compared to the more subjective hybrid approach. METHODS: Three surgical planning modalities were retrospectively analyzed in 43 legs scheduled for MOWHTO between 2015 and 2019. The planning modalities included: (1) 3D hybrid (3D non-weight-bearing (NWB) CT models after manual adaption of the opening angle considering the WB state in LLR, (2) 3D NWB (3D NWB CT models) and (3) 3D WB (2D/3D registration of 3D NWB CT models onto LLR to simulate the WB state). The pre- and postoperative hip-knee-ankle angle (HKA) and the planned opening angle (°) were assessed and differences among modalities reported. The relationship between the reported differences and BMI, preoperative HKA (LLR), medial meniscus extrusion, Outerbridge osteoarthritis grade and joint line convergence angle (JLCA) was analyzed. RESULTS: The mean (std) planned opening angle of 3D hybrid did not differ between 3D hybrid and 3D WB (0.4 ± 2.1°) (n.s.) but was higher in 3D hybrid compared to 3D NWB (1.1° ± 1.1°) (p = 0.039). 3D WB demonstrated increased preoperative varus deformity compared to 3D NWB: 6.7 ± 3.8° vs. 5.6 ± 2.7° (p = 0.029). Patients with an increased varus deformity in 3D WB compared to 3D NWB (> 2 °) demonstrated more extensive varus alignment in LLR (p = 0.009) and a higher JLCA (p = 0.013). CONCLUSION: Small intermodal differences between the current practice of the reported 3D hybrid planning modality and a 3D WB approach using a 2D/3D registration algorithm were reported. In contrast, neglecting the WB state underestimates preoperative varus deformity and results in a smaller planned opening angle. This leads to potential under correction in MOWHTO, especially in patients with extensive varus deformities or JLCA. CLINICAL RELEVANCE: Incorporating the WB state in 3D planning modalities has the potential to increase accuracy and lead to a more consistent and reliable planning in MOWHTO. The inclusion of the WB state in automatized surgical planning algorithms has the potential to reduce costs and time in the future.

Influence of medial open wedge high tibial osteotomy on tibial tuberosity-trochlear groove distance.

PURPOSE: Medial open wedge high tibial osteotomy (MOWHTO) is an effective treatment option for realignment of a varus knee. However, a simple supra-tuberositary osteotomy can lead to patella baja and potentially increases the tibial tuberosity-trochlear groove distance (TTTG). The purpose of this study was to quantify the influence of MOWHTO on TTTG. METHODS: Three-dimensional (3D) surface models of five lower extremities with a varus hip-knee-ankle angle (HKA) and a borderline TTTG (≥ 15 mm), five lower extremities with a varus HKA and a normal TTTG (< 15 mm) and a 3D statistical shape model (SSM) of a neutrally aligned healthy knee were analysed by simulating MOWHTO with a stepwise increment of one degree of valgisation from the preoperative coronal deformity (0°-15°) for each patient, resulting in a total of 165 simulations. Postoperative 3D TTTG and tibial torsion (TT) were measured for each simulation. A mathematical formula was developed to calculate the increase of TTTG after MOWHTO. Mean differences between simulated and calculated TTTG were analysed. RESULTS: Mean preoperative HKA was 6.5 ± 3.0° varus (range 0.8°-11.5°). Mean TTTG increased from 14.2 ± 3.2 mm (range 9.6-19.1) preoperatively to 18.8 ± 3.8 mm (range 14.5-25.0) postoperatively (p = 0.001). TTTG increased approximately linear by + 0.5 ± 0.2° (range 0.3-0.8) per 1° of valgisation with a high positive correlation (0.99, p = 0.001) from 0° to 15°. Mean difference between simulated and calculated TTTG was 0.03 ± 0.02 mm (range 0.01-0.07) per 1° of valgisation (p < 0.001). CONCLUSION: MOWHTO results in an approximately linear increase in TTTG of + 0.5 mm per 1° of valgisation in the range from 0° to 15° and the lateralisation of the tibial tuberosity can be calculated reliably using the described formula. Preoperative analysis of TTTG in patients undergoing MOWHTO may prevent unintentional patellofemoral malalignment. LEVEL OF EVIDENCE: III.

Decrease of tibial tuberosity trochlear groove distance following mechanically aligned total knee arthroplasty.

PURPOSE: Anterior knee pain (AKP) is common following total knee arthroplasty. The tibial tuberosity trochlear groove distance (TTTG) influences patellofemoral joint loading in the native knee. Increased TTTG may lead to maltracking of the patella and anterior knee pain. The purpose of this study was to investigate potential changes in TTTG following total knee arthroplasty (TKA). METHODS: TTTG was measured on preoperative CT data on a consecutive series of patients scheduled to receive TKA with patient-specific instrumentation, and compared to a computer simulation of the postoperative TTTG. Preoperative TTTG was measured with a 3D planning software in 250 knees. The postoperative result was simulated and TTTG measured within the software. Three different groups were analysed: neutral (180° ± 3) (n = 50), valgus (> 190°) (n = 100), and varus (< 170°) (n = 100). RESULTS: Median preoperative to simulated postoperative TTTG decreased from 15.0 [interquartile range (IQR) 6.0] mm to 6.5 (IQR 5.0) mm for all axes combined. A significant postoperative reduction of TTTG was found in each group (p < 0.001). The mean change in TTTG did not differ significantly between the groups [- 8.8 (IQR 5.5) mm neutral, - 8.3 (IQR 7.0) mm valgus, - 7.5 (IQR 5.8) mm varus, p = 0.223]. CONCLUSION: This computer-based study suggests that mechanically aligned TKA significantly decreases TTTG distance in neutral, valgus and varus knees, assuming that the postoperative result coincides with the preoperative planning. Further study is warranted to evaluate the clinical relevance of this finding.

Increased femoral curvature and trochlea flexion in high-grade patellofemoral dysplastic knees.

PURPOSE: High-grade patellofemoral dysplasia is often associated with concomitant axial and frontal leg malalignment. However, curvature of the femur and sagittal flexion of the trochlea has not yet been studied in patellofemoral dysplastic knees. The aim of the study was to quantify the femoral curvature and sagittal flexion of the trochlea in both high-grade patellofemoral dysplastic and healthy knees. METHODS: A retrospective case-control study matched 19 high-grade patellofemoral dysplastic knees (Dejour types C and D) with 19 healthy knees according to sex and body mass index. Three-dimensional (3D) femoral curvature and sagittal trochlea flexion were analysed. To analyse femoral curvature, the specific 3D radius of curvature (ROC) was calculated. Trochlear flexion was quantified through the development of the trochlea flexion angle (TFA), which is a novel 3D measurement in relation to the anatomical and mechanical femur axis and is referred to as 3D TFAanatomic and 3D TFAmech. The influence of age, gender, height, weight and frontal and axial alignment on ROC and TFA was analysed in a multiple regression model. RESULTS: Overall ROC was significantly smaller in dysplastic knees, compared with the control group [898.4 ± 210.8 mm (range 452.9-1275.1 mm) vs 1308.4 ± 380.5 mm (range 878.3-2315.8 mm), p < 0.001]. TFA was significantly higher in dysplastic knees, compared with the control group, for 3D TFAmech [13.8 ± 7.2° (range 4.4-33.4°) vs 6.5 ± 2.3° (range 0.8-10.2°), p < 0.001] and 3D TFAanatomic [12.5 ± 7.2° (range 3.1-32.2°) vs 6.4 ± 1.9° (range 2.1-9.1°), p = 0.001]. A smaller ROC was associated with smaller height, female gender and higher femoral ante torsion. An increased TFA was associated with valgus malalignment. CONCLUSION: High-grade patellofemoral dysplastic knees demonstrated increased femoral curvature and sagittal flexion of the trochlea, compared with healthy knees. The ROC and newly described TFA allowed the quantification of the sagittal femoral deformity. TFA and ROC should be incorporated in future deformity analysis to investigate their potential as a target for surgical correction. LEVEL OF EVIDENCE: Level III.

No relevant mechanical leg axis deviation in the frontal and sagittal planes is to be expected after subtrochanteric or supracondylar femoral rotational or derotational osteotomy.

PURPOSE: The purpose of this study was to investigate if one level of corrective femoral osteotomy (subtrochanteric or supracondylar) bears an increased risk of unintentional implications on frontal and sagittal plane alignment in a simulated clinical setting. METHODS: Out of 100 cadaveric femora, 23 three-dimensional (3-D) surface models with femoral antetorsion (femAT) deformities (> 22° or < 2°) were investigated, and femAT normalized to 12° with single plane rotational osteotomies, perpendicular to the mechanical axis of the femur. Change of the frontal and sagittal plane alignment was expressed by the mechanical lateral distal femoral angle (mLDFA) and the posterior distal femoral angle (PDFA), respectively. The influence of morphologic factors of the femur [centrum-collum-diaphyseal (CCD) angle and antecurvatum radius (ACR)] were assessed. Furthermore, position changes of the lesser (LT) and greater trochanters (GT) in the frontal and sagittal plane compared to the hip centre were investigated. RESULTS: Mean femoral derotation of the high-antetorsion group (n = 6) was 12.3° (range 10-17°). In the frontal plane, mLDFA changed a mean of 0.1° (- 0.06 to 0.3°) (n.s.) and - 0.3° (- 0.5 to - 0.1) (p = 0.03) after subtrochanteric and supracondylar osteotomy, respectively. In the sagittal plane, PDFA changed a mean of 1° (0.7 to 1.1) (p = 0.03) and 0.3° (0.1 to 0.7) (p = 0.03), respectively. The low-antetorsion group (n = 17) was rotated by a mean of 13.8° (10°-23°). mLDFA changed a mean of - 0.2° (- 0.5° to 0.2°) (p < 0.006) and 0.2° (0-0.5°) (p < 0.001) after subtrochanteric and supracondylar osteotomy, respectively. PDFA changed a mean of 1° (- 2.3 to 1.3) (p < 0.01) and 0.5° (- 1.9 to 0.3) (p < 0.01), respectively. The amount of femAT correction was associated with increased postoperative deviation of the mechanical leg axis (p < 0.01). Using multiple regression analysis, no other morphological factors were found to influence mLDFA or PDFA. Internal rotational osteotomies decreased the ischial-lesser trochanteric space by < 5 mm in both the frontal and sagittal plane (p < 0.001). CONCLUSIONS: In case of femAT correction of ≤ 20°, neither subtrochanteric nor supracondylar femoral derotational or rotational osteotomies have a clinically relevant impact on frontal or sagittal leg alignment. A relevant deviation in the sagittal (but not frontal plane) might occur in case of a > 25° subtrochanteric femAT correction. LEVEL OF EVIDENCE: IV.

Extent of posterolateral tibial plateau impaction fracture correlates with anterolateral complex injury and has an impact on functional outcome after ACL reconstruction.

PURPOSE: The impact of posterolateral tibial plateau impaction fractures (TPIF) on posttraumatic knee stability in the setting of primary anterior cruciate ligament (ACL) tear is unknown. The main objective was to determine whether increased bone loss of the posterolateral tibial plateau is associated with residual rotational instability and impaired functional outcome after ACL reconstruction. METHODS: A cohort was identified in a prospective enrolled study of patients suffering acute ACL injury who underwent preoperative standard radiographic diagnostics and clinical evaluation. Patients were included when scheduled for isolated single-bundle hamstring autograft ACL reconstruction. Exclusion criteria were concurrent anterolateral complex (ALC) reconstruction (anterolateral tenodesis), previous surgery or symptoms in the affected knee, partial ACL tear, multi-ligament injury with an indication for additional surgical intervention, and extensive cartilage wear. On MRI, bony (TPIF, tibial plateau, and femoral condyle morphology) and ligament status (ALC, concomitant collateral ligament, and meniscus injuries) were assessed by a musculoskeletal radiologist. Clinical evaluation consisted of KT-1000, pivot-shift, and Lachman testing, as well as Tegner activity and IKDC scores. RESULTS: Fifty-eight patients were included with a minimum follow-up of 12 months. TPIF was identified in 85% of ACL injuries (n = 49). The ALC was found to be injured in 31 of 58 (53.4%) cases. Pearson analysis showed a positive correlation between TPIF and the degree of concomitant ALC injury (p < 0.001). Multiple regression analysis revealed an increased association of high-grade TPIF with increased lateral tibial convexity (p = 0.010). The high-grade TPIF group showed worse postoperative Tegner scores 12 months postoperatively (p = 0.035). CONCLUSION: Higher degrees of TPIFs are suggestive of a combined ACL/ALC injury. Moreover, patients with increased posterolateral tibial plateau bone loss showed lower Tegner activity scores 12 months after ACL reconstruction. LEVEL OF EVIDENCE: III.

Excessive femoral torsion is not associated with patellofemoral pain or instability if TKA is functionally aligned and the patella denervated.

PURPOSE: Recent data suggest that individual morphologic factors should be respected to restore preoperative patellofemoral alignment and thus reduce the likelihood of anterior knee pain. The goal of this study was to investigate the effect of excessive femoral torsion (FT) on clinical outcome of TKA. METHODS: Patients who underwent TKA and complete preoperative radiographic evaluation including a long-leg radiograph and CT scan were included. 51 patients showed increased FT of > 20° and were matched for age/sex to 51 controls (FT < 20°). Thirteen patients were lost to follow-up. Thirty-eight matched pairs were compared after a 2 year follow-up clinically (Kujala and patellofemoral score for TKA) and radiographically (FT, frontal leg axis, TT-TG, patellar thickness, patellar tilt, and lateral displacement of patella). Functional alignment of TKA was performed (hybrid-technique). All patellae were denervated but no patella was resurfaced. RESULTS: There was no significant difference between clinical scores two years after surgery between patients with normal and excessive FT (n.s.). Kujala score was 64.3 ± 16.7 versus 64.8 ± 14.4 (n.s.), and patellofemoral score for TKA was 74.3 ± 21 versus 78.5 ± 20.7 (n.s.) for increased FT group and control group, respectively. There was no correlation between preoperative FT and clinical scores. Other radiographic parameters were similar between both groups. No correlations between clinical outcomes and preoperative/postoperative frontal leg axis or total leg axis correction were found (n.s.). CONCLUSION: If the leg axis deformity is corrected to a roughly neutral alignment during cemented TKA, including patellar denervation, then excessive FT was not associated with patellofemoral pain or instability. LEVEL OF EVIDENCE: Prospective comparative study, level II.

The relationship between pelvic tilt, frontal, and axial leg alignment in healthy subjects.

INTRODUCTION: The relationship between anterior pelvic tilt and overall sagittal alignment has been well-described previously. However, the relationship between pelvic tilt, frontal, and axial leg alignment remains unclear. The aim of the study was to analyze the relationship between pelvic tilt and frontal and axial leg alignment in healthy subjects. MATERIAL AND METHODS: Thirty healthy subjects (60 legs) without prior surgery underwent standing biplanar long leg radiograph. Pelvic parameters (pelvic tilt, pelvic incidence, sacral slope), hip-knee-ankle angle (HKA), femoral antetorsion and tibial torsion were measured using SterEOS (EOS Imaging) software. EOS was acquired with the feet directing straight anteriorly, which corresponds to a neutral foot progression angle (FPA). The influence of HKA, femoral antetorsion, tibial torsion and gender on pelvic tilt was analyzed in a univariate correlation and multiple regression model. RESULTS: Sixteen female subjects and 14 male subjects with a mean age of 27.1 years ± 10 (range 20-67) were included. HKA, femoral antetorsion, and tibial torsion correlated with anterior pelvic tilt in univariate analysis (all p < 0.05). Anterior pelvic tilt increased 1.1° (95% CI: 0.7 to 1.5) per 1° of knee valgus (p < 0.001) and 0.5° (95% CI: 0.3 to 0.7) per 1° of external tibial torsion (p < 0.001). Overall, linear regression model fit explained 39% of variance in pelvic tilt by the HKA, femoral antetorsion and tibial torsion (R2 = 0.385; p < 0.001). CONCLUSION: Valgus alignment and increasing tibial torsion demonstrated a weak correlation with an increase in anterior pelvic tilt in healthy subjects when placing their feet anteriorly. The relationship between frontal, axial leg alignment and pelvic tilt needs to be considered in patients with multiple joint disorders at the hip, knee and spine. Alteration of the frontal, or rotational profile after realignment surgery or by implant positioning might influence the pelvic tilt when the FPA is kept constant.

Tibial tunnel enlargement is affected by the tunnel diameter-screw ratio in tibial hybrid fixation for hamstring ACL reconstruction.

INTRODUCTION: There is no evidence on screw diameter with regards to tunnel size in anterior cruciate ligament reconstruction (ACLR) using hybrid fixation devices. The hypothesis was that an undersized tunnel coverage by the tibial screw leads to subsequent tunnel enlargement in ACLR in hybrid fixation technique. METHODS: In a retrospective case series, radiographs and clinical scores of 103 patients who underwent primary hamstring tendon ACLR with a hybrid fixation technique at the tibial site (interference screw and suspensory fixation) were obtained. Tunnel diameters in the frontal and sagittal planes were measured on radiographs 6 weeks and 12 months postoperatively. Tunnel enlargement of more than 10% between the two periods was defined as tunnel widening. Tunnel coverage ratio was calculated as the tunnel diameter covered by the screw in percentage. RESULTS: Overall, tunnel widening 12 months postoperatively was 23.1 ± 17.1% and 24.2 ± 18.2% in the frontal and sagittal plane, respectively. Linear regression analysis revealed the tunnel coverage ratio to be a negative predicting risk factor for tunnel widening (p = 0.001). The ROC curve analysis provided an ideal cut-off for tunnel enlargement of > 10% at a tunnel coverage ratio of 70% (sensitivity 60%, specificity 81%, AUC 75%, p < 0.001). Patients (n = 53/103) with a tunnel coverage ratio of < 70% showed significantly higher tibial tunnel enlargement of 15% in the frontal and sagittal planes. The binary logistic regression showed a significant OR of 6.9 (p = 0.02) for tunnel widening > 10% in the frontal plane if the tunnel coverage ratio was < 70% (sagittal plane: OR 14.7, p = 0.001). Clinical scores did not correlate to tunnel widening. CONCLUSION: Tibial tunnel widening was affected by the tunnel diameter coverage ratio. To minimize the likelihood of disadvantageous tunnel expansion-which is of importance in case of revision surgery-an interference screw should not undercut the tunnel diameter by more than 1 mm.

Tibial internal rotation in combined anterior cruciate ligament and high-grade anterolateral ligament injury and its influence on ACL length.

BACKGROUND: Assessment of combined anterolateral ligament (ALL) and anterior cruciate ligament (ACL) injury remains challenging but of high importance as the ALL is a contributing stabilizer of tibial internal rotation. The effect of preoperative static tibial internal rotation on ACL -length remains unknown. The aim of the study was analyze the effect of tibial internal rotation on ACL length in single-bundle ACL reconstructions and to quantify tibial internal rotation in combined ACL and ALL injuries. METHODS: The effect of tibial internal rotation on ACL length was computed in a three-dimensional (3D) model of 10 healthy knees with 5° increments of tibial internal rotation from 0 to 30° resulting in 70 simulations. For each step ACL length was measured. ALL injury severity was graded by a blinded musculoskeletal radiologist in a retrospective analysis of 61 patients who underwent single-bundle ACL reconstruction. Preoperative tibial internal rotation was measured in magnetic resonance imaging (MRI) and its diagnostic performance was analyzed. RESULTS: ACL length linearly increased 0.7 ± 0.1 mm (2.1 ± 0.5% of initial length) per 5° of tibial internal rotation from 0 to 30° in each patient. Seventeen patients (27.9%) had an intact ALL (grade 0), 10 (16.4%) a grade 1, 21 (34.4%) a grade 2 and 13 (21.3%) a grade 3 injury of the ALL. Patients with a combined ACL and ALL injury grade 3 had a median static tibial internal rotation of 8.8° (interquartile range (IQR): 8.3) compared to 5.6° (IQR: 6.6) in patients with an ALL injury (grade 0-2) (p = 0.03). A cut-off > 13.3° of tibial internal rotation predicted a high-grade ALL injury with a specificity of 92%, a sensitivity of 30%; area under the curve (AUC) 0.70 (95% CI: 0.54-0.85) (p = 0.03) and an accuracy of 79%. CONCLUSION: ACL length linearly increases with tibial internal rotation from 0 to 30°. A combined ACL and high-grade ALL injury was associated with greater preoperative tibial internal rotation. This potentially contributes to unintentional graft laxity in ACL reconstructed patients, in particular with concomitant high-grade ALL tears. STUDY DESIGN: Cohort study; Level of evidence, 3.

The winking sign is an indicator for increased femorotibial rotation in patients with recurrent patellar instability.

PURPOSE: Rotation of the tibia relative to the femur was recently identified as a contributing risk factor for patellar instability, and correlated with its severity. The hypothesis was that in patellofemoral dysplastic knees, an increase in femorotibial rotation can be reliably detected on anteroposterior (AP) radiographs by an overlap of the lateral femoral condyle over the lateral tibial eminence. METHODS: Sixty patients (77 knees) received low-dose computed tomography (CT) of the lower extremity for assessment of torsional malalignment due to recurrent patellofemoral instability. Three-dimensional (3D) surface models were created to assess femorotibial rotation and its relationship to other morphologic risk factors of patellofemoral instability. On weight-bearing AP knee radiographs, a femoral condyle/lateral tibial eminence superimposition was defined as a positive winking sign. Using digitally reconstructed radiographs of the 3D models, susceptibility of the winking sign to vertical/horizontal AP knee radiograph malrotation was investigated. RESULTS: A positive winking sign was present in 30/77 knees (39.0%) and indicated a 6.3 ± 1.4° increase in femorotibial rotation (p < 0.001). Femoral condyle/tibial eminence superimposition of 1.9 mm detected an increased femorotibial rotation (> 15°) with 43% sensitivity and 90% specificity (AUC = 0.72; p = 0.002). A positive winking sign (with 2 mm overlap) disappeared in case of a 10° horizontally or 15° vertically malrotated radiograph, whereas a 4 mm overlap did not disappear at all, regardless of the quality of the radiograph. In absence of a winking sign, on the other hand, no superimposition resulted within 20° of vertical/horizontal image malrotation. Femorotibial rotation was positively correlated to TT-TG (R2 = 0.40, p = 0.001) and patellar tilt (R2 = 0.30, p = 0.001). CONCLUSIONS: The winking sign reliably indicates an increased femorotibial rotation on a weight-bearing AP knee radiograph and could prove useful for day-by-day clinical work. Future research needs to investigate whether femorotibial rotation is not only a prognostic factor but a potential surgical target in patients with patellofemoral disorders. LEVEL OF EVIDENCE: III.

The effect of native knee rotation on the tibial-tubercle-trochlear-groove distance in patients with patellar instability: an analysis of MRI and CT measurements.

BACKGROUND: This study aimed to quantify the effect of lower limb rotational parameters on the difference in the tibial-tubercle-trochlear-groove (TTTG) distance when assessed with magnetic resonance imaging (MRI) and computed tomography (CT) in patients with patellar instability. It was hypothesized that an increased native knee rotation angle significantly contributes to an underestimation of TTTG by MRI. METHODS: Forty patients with patellar instability who had undergone standard radiographs, MRI and CT scans were included in this retrospective study. A musculoskeletal radiologist assessed all imaging for TTTG, femoral and tibial rotation, knee rotation and flexion angle, and trochlear dysplasia. ΔTTTG was defined as the TTTG measured on MRI subtracted from the TTTG measured on CT. Statistical analysis determined the effect of these parameters on the calculated difference between TTTG when measured on CT and MRI. RESULTS: Equal knee flexion in MRI and CT resulted in a ΔTTTG of 0.1 ± 0.3 mm compared to 4.0 ± 3.3 mm in patients with different knee flexion angles in both imaging acquisitions (p = 0.036). The knee rotation angle measured on CT (native knee rotation angle) was negatively correlated with ΔTTTG (r = - 0.365; p = 0.002), while neither tibial nor femoral rotation showed any associations with TTTG (n.s.). Trochlear dysplasia did not show any significant correlation with ΔTTTG, regardless of classification by Dejour or Lippacher (n.s.). Both the native knee rotation angle and the MRI knee flexion angle were independent predictors of ΔTTTG, yet with an opposing effect (knee rotation: 95% Confidence Interval [CI] for ß - 0.468 to - 0.154, p < 0.001; knee flexion 95% CI for ß 0.292 to 0.587, p < 0.001). Patients with a native knee rotation angle > 20° showed a ΔTTTG of - 5.8 ± 4.0 mm (MRI rather overestimates TTTG) compared to 0.9 ± 4.1 mm Δ TTTG (MRI rather underestimates TTTG) in patients with < 20° native knee rotation angle. CONCLUSION: The native knee rotation angle is an independent, inversely correlated predictor of ΔTTTG, thus opposing the effect of knee flexion during MRI acquisition. Consequently, these results suggest that not only knee flexion but also knee rotation should be appreciated when assessing TTTG during patellar instability diagnostic evaluation as it can potentially lead to a false estimation of the TTTG distance on MRI. LEVEL OF EVIDENCE: Level III.

Ultra-high resolution 3D MRI for chondrocalcinosis detection in the knee-a prospective diagnostic accuracy study comparing 7-tesla and 3-tesla MRI with CT.

OBJECTIVES: To test the diagnostic accuracy of a 3D dual-echo steady-state (DESS) sequence at 7-T MRI regarding the detection of chondral calcific deposits of the knee in comparison to 3-T MRI, using CT as cross-sectional imaging reference standard. METHODS: CT and 7-T MRI (DESS) of knee joints in 42 patients with radiographically known chondrocalcinosis (13 of 42 bilateral) were prospectively acquired for all included patients (n = 55 knee joints). Additionally, 3-T MRI (DESS) was performed for 20 of these 55 knee joints. Two fellowship-trained musculoskeletal radiologists scored eight cartilage regions of each knee joint separately regarding presence of cartilage calcification, diagnostic confidence level, and sharpness of calcific deposits. In an explorative subanalysis, micro-CT of the menisci was evaluated after knee arthroplasty in one patient. Diagnostic performance metrics and nonparametric tests were used to compare between modalities. p values < 0.05 were considered to represent statistical significance. RESULTS: Sensitivity for chondrocalcinosis detection was significantly higher for 7-T MRI (100%) compared to 3-T MRI (reader 1: 95.9%, p = 0.03; reader 2: 93.2%, p = 0.002). The diagnostic confidence was significantly higher for both readers at 7 T compared to both 3-T MRI (p < 0.001) and to CT (p = 0.03). The delineation of chondral calcifications was significantly sharper for 7-T compared to both 3-T MRI and CT (p < 0.001, both readers). Micro-CT in one patient suggested that 7-T MRI may potentially outperform standard CT in diagnosing chondral calcifications. CONCLUSION: 3D-DESS imaging at 7-T MRI offers a significantly higher sensitivity in detection of chondral calcific deposits compared to 3-T MRI. KEY POINTS: • 3D dual-echo steady-state (DESS) MRI at 7 T has a higher sensitivity in detection of chondral calcific deposits compared to 3-T MRI (p ≤ 0.03). • 3D DESS MRI at 7 T yields no false-negative cases regarding presence of chondral calcific deposits. • 3D DESS MRI at 7 T offers better delineation and higher diagnostic confidence in detection of chondral calcific deposits compared to 3-T MRI (p < 0.001).

Risk factor analysis for above-knee amputation in patients with periprosthetic joint infection of the knee: a case-control study.

BACKGROUND: Periprosthetic joint infection (PJI) is a severe complication following knee arthroplasty. Therapeutic strategies comprise a combination of surgical and antibiotic treatment modalities and aim to eradicate the infection. Sometimes control of the disease can only be attained by above-knee amputation (AKA). While a vast amount of literature exists illuminating predisposing factors for PJI, risk factors favoring the endpoint AKA in this context are sparsely known. METHODS: The purpose of this investigation was to delineate whether patients with PJI of the knee present specific risk factors for AKA. In a retrospective case-control study 11 cases of PJI treated with AKA were compared to 57 cases treated with limb salvage (LS). The minimum follow-up was 2 years. Comorbidities, signs and symptoms of the current infection, factors related to previous surgeries and the implant, microbiology, as well as therapy related factors were recorded. Comparative analysis was performed using student's t-test, chi-square test or Fisher's exact test. Binary differences were calculated using odds ratio (OR). Reoperation frequency was compared using Mann-Whitney U test. In-depth descriptive analysis of 11 amputees was carried out. RESULTS: A total of 68 cases aged 71 ± 11.2 years were examined, 11 of which underwent AKA and 57 had LS. Severe comorbidities (p = 0.009), alcohol abuse (p = 0.015), and preoperative anemia (p = 0.022) were more frequently associated with AKA. Preoperative anemia was found in all 11 amputees (100%) and in 33 of 57 LS patients (58%) with an average preoperative hemoglobin of 99.9 ± 15.1 g/dl compared to 118.2 ± 19.9 g/dl (p = 0.011). No other parameters differed significantly. AKA patients underwent a median of eight (range 2-24) reoperations, LS patients a median of five (range 2-15). CONCLUSION: Factors potentially influencing the outcome of knee PJI are diverse. The indication of AKA in this context remains a rarity and a case-by-case decision. Patient-intrinsic systemic factors such as alcohol abuse, severe comorbidities and preoperative anemia may elevate the individual risk for AKA in the setting of PJI. We recommend that anemia, being a condition well amenable to therapeutic measures, should be given special consideration in management of PJI patients. TRIAL REGISTRATION: This study was registered with Kantonale Ethikkommission Zürich, (BASEC-No. 2016-01048).

Injury risks among elite competitive alpine skiers are underestimated if not registered prospectively, over the entire season and regardless of whether requiring medical attention.

PURPOSE: Prospective studies assessing the injuries occurring in elite competitive alpine skiers are lacking, and a full picture of all injuries, including those not requiring medical attention, is absent. Likewise, little is known about the sex-specific injury risks and patterns of elite skiers throughout an entire season (i.e. an off-season preparation period and a competition period). Accordingly, this study investigated the injuries of a national team cohort with respect to season period and sex. METHODS: Over an entire season, all injuries occurring in 44 Swiss National Ski Team members (25 females and 19 males) were registered, regardless of whether they required medical attention. Skiers were prospectively monitored by the Oslo Sports Trauma Research Centre (OSTRC) questionnaire and by continuously updated team medical records. Finally, these data were used as a reference for supplemental interviews, in which the correctness and completeness of the prospective data were verified. RESULTS: The risk of suffering at least one injury during an entire season was 75.0% with a 95% confidence interval (73.1%, 76.9%) for traumatic injuries, and 52.3% (50.0%, 54.5%) for overuse injuries. Traumatic injuries concerned the head, lower leg and knee, while overuse injuries affected the lumbar spine, knee and hip. During the competition period, skiers were more prone to traumatic injuries, while during the off-season preparation period, skiers' risk was higher for overuse injuries. Over an entire season, there were no sex differences. However, females were more vulnerable to traumatic injuries during the preparation period and overuse injuries during the competition period, while males had a higher risk for overuse injuries during the preparation period. CONCLUSIONS: When prospectively registering injuries among elite competitive alpine skiers over an entire season, regardless of whether the injuries required medical attention, the injury risks were alarmingly high and substantially larger than those previously reported. Moreover, since injury risks and patterns are season period and sex dependent, it is strongly recommended that (1) injury registration focuses on both the off-season preparation period and the competition period and (2) prevention efforts are specifically tailored to the sex of the athletes. LEVEL OF EVIDENCE: II.

Factors affecting outcome in the treatment of streptococcal periprosthetic joint infections: results from a single-centre retrospective cohort study.

PURPOSE: To report and analyse factors affecting the outcome of streptococcal periprosthetic joint infections (PJIs). METHODS: A retrospective analysis of consecutive streptococcal PJIs was performed. Musculoskeletal Infection Society 2013 criteria were used. Outcome was compared with a prospective PJI cohort from the same institution. RESULTS: The most common isolated streptococcal species was Streptococcus dysgalactiae (9/22, 41%) among 22 patients included. Surgical treatment consisted of DAIR (debridement, antibiotics, irrigation and retention) in 12 (55%), one-stage revision arthroplasty in one (4%), two-stage revision arthroplasty in eight (37%) and implant removal in one (4%) patient. An infection free-outcome was achieved in 15 cases (68%), whilst seven (32%) patients failed initial revision and relapsed with the same pathogen, from which six were treated with DAIR and one with one-stage revision arthroplasty. No failures were observed in patients who received a two-stage revision. Failure rates did not differ in the cases treated with rifampin (1/5) from those without 6/17 (p = 0.55). There was no correlation between the length of antibiotic treatment and relapse (p = 0.723). In all failures, a persistent distant infection focus was identified at the time of relapse. Compared with our prospective PJI cohort, relapse rates were significantly higher 32% vs 12% (p < 0.05). CONCLUSION: No correlation with the use of rifampin or length of antibiotic treatment was found. No failures were observed in patients who received a two-stage revision, which may be the surgical treatment of choice. A distant persisting infection focus could be the reason for PJI relapse with recurrent hematogenous seeding in the joint.