Level II-prospective comparative study.

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.

Bone tunnel enlargement is a well-established phenomenon following anterior cruciate ligament (ACL) reconstruction, and is related to soft tissue grafts, suspension fixation devices, and absorbable implants. Severe tunnel enlargement can lead to reconstruction failure. The correlation between bone tunnel enlargement following ACL reconstruction and original bone tunnel diameter has not been elucidated. To determine whether bone tunnel enlargement after ACL reconstruction with hamstring autograft is dependent on original tunnel diameter established during primary ACL reconstruction. A retrospective review was conducted on 56 patients scheduled for ACL revision surgery who had undergone computed tomography (CT) scanning as part of their preoperative evaluation. All patients had undergone previous hamstring ACL reconstruction. Original femoral and tibial bone tunnel diameters were extracted from operative reports, and femoral and tibial bone tunnel enlargement was assessed on CT serial sections. The correlation between original tunnel diameter and bone tunnel enlargement was investigated using regression analysis. Mean tibial bone tunnel enlargement was significantly and inversely dependent on the original tibial bone tunnel diameter with a correlation coefficient of -0.55 per unit (7 mm = +1.93 mm, 8 mm = +1.43 mm, 9 mm = 0.83 mm, = 0.007). Thus, every additional increase (mm) in diameter of the original tibial bone tunnel reduces the extend of tunnel widening by 0.55 mm. The results of this study indicate that tibial bone tunnel enlargement following ACL reconstruction is dependent on original tibial bone tunnel diameter with smaller diameter tunnels developing more tunnel enlargement than larger tunnels. The contributing factors remain unclear and need to be further investigated.

Background  Increased tibial slope has been shown to be associated with higher anterior cruciate ligament (ACL) reconstruction failure rate. Little is known about the correlation of tibial slope and anterior tibial translation in ACL deficient and reconstructed knees as well as the correlation of tibial slope and ACL reconstruction outcome. Purpose/Hypothesis  The purpose of this study was to investigate the correlation of tibial slope with anterior tibial translation and ACL reconstruction outcome. It is hypothesized that increased medial tibial slope is associated with increased anterior tibial translation in the ACL deficient knee. Medial tibial slope is neither expected to affect anterior tibial translation in the ACL reconstructed knee nor short-term ACL reconstruction outcome. Materials and Methods  A cohort of 104 patients with unilateral isolated ACL deficiency undergoing hamstring ACL reconstruction by a single surgeon between 2002 and 2004 was followed up prospectively. Preoperative data were collected including patient demographics, time to surgery, subjective and objective International Knee Documentation Committee (IKDC) outcome scores, as well as manual maximum anterior tibial translation measured with the KT-1000 measuring instrument. Medial tibial slope was assessed on long lateral X-rays using the method described by Dejour and Bonnin (1994). Intraoperative data were collected including meniscal integrity; postoperative data were collected at 1-year follow-up including manual maximum anterior tibial translation (KT-1000 measured), and subjective and objective IKDC scores. Results  A significant positive correlation was seen between medial tibial slope in ACL deficient knees and KT-1000–measured anterior tibial translation ( r  = 0.24; p  = 0.003). The positive relationship increased when meniscal integrity was factored in ( r  = 0.33; p  < 0.001). No significant correlation was seen between medial or lateral meniscal integrity and KT-1000–measured anterior tibial translation ( r  = −18; p  = 0.06). No significant correlation was seen between KT-1000–measured anterior tibial translation and time to surgery. One year postoperatively, 82 patients were assessed, while 26 patients were lost to follow-up; no significant correlation was found between increased medial tibial slope and poor ACL reconstruction outcome measured by post-ACL reconstruction anterior tibial translation (KT-1000) or subjective and objective IKDC scores. Conclusion  Increased medial tibial slope is associated with increased (KT-1000 measured) anterior tibial translation in ACL deficient knees. No significant correlation is found between increased medial tibial slope and poor short-term ACL reconstruction outcome.

Background: Increased lateral tibial posterior slope (LTPS) is associated with higher anterior cruciate ligament (ACL) reconstruction (ACLR) failure rate. Transportal central femoral footprint ACLR is associated with higher failure rate compared to transtibial high anteromedial footprint ACLR due to graft anisometry. The purpose of this study was to investigate whether the influence of tibial slope on ACL graft failure risk is dependent on graft positioning. Material: Of the 1480 consecutive hamstring ACLRs, 30 transportal (central femoral tunnel placement) and 30 transtibial (high anteromedial tunnel placement) ACLR failures were evaluated and matched one-to-one with non-failure control participants by age, sex, graft and surgical technique. Lateral tibial slope was assessed on MRI. Results: The risk of graft failure in the transportal group increased by 40.5% per degree of increasing LTPS (odds ratio 1.4; 95% confidence interval 1.05–1.87; p = 0.02). The transportal failure group showed a significantly higher mean tibial slope of 8.6° compared to both the transportal control group with 7.1° (p = 0.03) and the transtibial failure group with 7.2° (p = 0.04). Increased tibial slope was associated with shorter time to reconstruction failure (p = 0.002). The difference between slopes in the transtibial failure group (7.2°) compared to the transtibial control group (7.1°) was not significant (p = 0.56). Conclusion: Increased LTPS is associated with significantly increased risk of graft failure only in transportal ACLR, not in transtibial ACLR. Slope-related graft strain may be potentiated by anisometric ACL graft placement.

First described by Kavanaugh et al in 1978, intramedullary screw fixation is still indicated for proximal fifth metatarsal fractures.1 The simple percutaneous technique allows stable fracture fixation and thus early postoperative weight-bearing and rapid return to preinjury level of competitive sport. 2However, in terms of prognosis, tuberosity avulsion fractures (►Fig. 1; zone 1) must be distinguished from both traumatic fractures at the metaphyseal-diaphyseal junction (true Jones fracture; ►Fig. 1; zone 2) as well as proximal diaphyseal stress fractures (►Fig. 1; zone 3). The latter are a result of repetitive loading leading to failure of the skeletal structure and are associated with longer consolidation times and complications.3 Pes cavus and hindfoot varus foot alignment has been identified to potentiate cyclic loading onto the fifth metatarsal, which favors the incidence of a stress fracture. What is more, diaphyseal blood supply of the fifth metatarsal is ensured solely by the nutrient artery and may therefore be compromised when a diaphyseal fracture occurs, which may subsequently impede fracture healing. 4 In spite of excellent results regarding intramedullary screw fixation for proximal fifth metatarsal fractures, screw breakage or bending has been reported and seems to be related to postoperative early weight-bearing, high patient body mass index (BMI), and the use of undersized screws. 5-7 An intramedullary screw fitting tightly may be of paramount importance. Case ReportA 19-year-old male professional basketball player presents with pain to the lateral border of his left foot. The symptoms commence immediately after perceiving a snap to the left foot while attempting to jump. Forced inversion or flexion of the foot during injury is denied. Radiographs confirm a transverse stress fracture of the fifth metatarsal (►Fig. 2). Upon clinical examination, bilateral pes cavus and hindfoot varus alignment including peek-a-boo heel sign is observed (►Fig. 3A, B). The patient is scheduled for intramedullary screw fixation with a 4.5-mm cannulated screw. Surgical TechniqueThe surgical procedure was performed in regional anesthesia. The fracture was identified using a fluoroscan C-arm, and a small incision was made proximal to the base of the fifth metatarsal. An intramedullary guidewire was inserted into the fifth metatarsal and placed across the fracture site. The guidewire was then overdrilled protecting the soft tissue and tendon attachment with a drill sleeve. Counterpressure was placed along the longitudinal axis of the fifth metatarsal, and a correct length screw was inserted and tightened. All threads were placed distal to the fracture site. The screw head was embedded into the cortical part of the styloid Keywords ► intramedullary screw fixation ► proximal fifth metatarsal fracture ► pes cavus ► hindfoot varus AbstractIntramedullary screw fixation of proximal fifth metatarsal fractures is a simple surgical procedure, enabling early postoperative weight-bearing and subsequently rapid return to competitiv...

Increased tibial slope is associated with increased risk of anterior cruciate ligament (ACL) injury in the skeletally immature. Recent studies, however, emphasize a mutual influence, as tibial slope has been shown to increase over time in the ACL-deficient skeletally immature knee. It is hypothesized that altered biomechanics with enhanced posterior force transmission in the ACL-deficient knee may influence the developing physis, leading to altered longitudinal growth and increased tibial slope. In addition to tibial slope, the meniscal geometry, including meniscal bone angle and meniscal slope, have been shown to influence the risk of ACL injury. In the skeletally immature knee, especially, the soft tissue geometry is thought to have significant impact on ACL injury risk. However, it remains unknown whether alteration of the meniscal slope may represent a causality of ACL deficiency.

No abstract