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Higher risk of contralateral anterior cruciate ligament (ACL) injury within 2 years after ACL reconstruction in under-18-year-old patients with steep tibial plateau slope

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To assess the role of Tibial Plateau Slope (TPS) as risk factor for early Anterior Cruciate Ligament (ACL) reconstruction failure and contralateral ACL injury in a population of patients with less than 18 years of age and operated on with the same surgical technique.

Methods

Ninety-four consecutive patients (mean age 15.7 ± 1.5 years) with at least 2 years of follow-up, who underwent ACL reconstruction with a single-bundle plus lateral-plasty hamstring technique in the same centre were included. Subsequent ACL injuries (ipsilateral ACL revision or contralateral ACL reconstruction) were assessed within the first 2 years after surgery. Anterior, central, posterior TPS of medial compartment were measured on lateral radiographs and compared between patients with intact graft and those with a second injury. Cut-off values with sensitivity and specificity were calculated with receiver operating characteristic (ROC) analysis. Survival analysis for second ACL injuries and multivariate analysis were performed.

Results

Eight patients (9%) had ipsilateral ACL Revision and eight patients (9%) had contralateral ACL reconstruction. Patients with contralateral injury had a higher Central TPS with respect to those without second injury (12.6° ± 2.8° vs 9.3° ± 3.7°, p = 0.042). No differences were present in patients with ipsilateral ACL revision. Sensitivity and specificity for central TPS slope ≥ 12° to detect a contralateral rupture were 63% and 75% (p = 0.0092), for Anterior TPS were 100% and 52% (p = 0.0009). Patients with TPS values exceeding these cut-offs had higher rate of contralateral ACL injuries (19%vs4%, p = 0.0420) and lower 2-year survival (p = 0.0049). Multivariate analysis identified pre-operative sport level and TPS (either anterior or central) as risk factors for contralateral injuries.

Conclusions

Steep tibial plateau slope ≥ 12° is associated with a higher risk of contralateral ACL injury within 2 years after ACL reconstruction in patients less than 18 years of age. However, TPS has no role in early ipsilateral re-injury after combined ACL reconstruction and lateral plasty. The clinical relevance is that both the surgeon and the patient should be aware of this higher risk and consider it in the rehabilitation phase to reduce the incidence of such injuries.

Level of evidence

III.

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References

  1. Ahmed I, Salmon L, Roe J, Pinczewski L (2017) The long-term clinical and radiological outcomes in patients who suffer recurrent injuries to the anterior cruciate ligament after reconstruction. Bone Jt J 99:337–343

    Article  Google Scholar 

  2. Bernhardson AS, Aman ZS, DePhillipo NN, Dornan GJ, Storaci HW, Brady AW, Nakama G, LaPrade RF (2019) Tibial slope and its effect on graft force in posterior cruciate ligament reconstructions. Am J Sports Med 47:1168–1174

    Article  Google Scholar 

  3. Christensen JJ, Krych AJ, Engasser WM, Vanhees MK, Collins MS, Dahm DL (2015) Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. Am J Sports Med 43:2510–2514

    Article  Google Scholar 

  4. Cooper JD, Wang W, Prentice HA, Funahashi TT, Maletis GB (2019) The association between tibial slope and revision anterior cruciate ligament reconstruction in patients ≤ 21 years old: a matched case-control study including 317 revisions. Am J Sports Med 47:3330–3338

    Article  Google Scholar 

  5. Dare DM, Fabricant PD, McCarthy MM, Rebolledo BJ, Green DW, Cordasco FA, Jones KJ (2015) Increased lateral tibial slope is a risk factor for pediatric anterior cruciate ligament injury: an MRI-based case-control study of 152 patients. Am J Sports Med 43:1632–1639

    Article  Google Scholar 

  6. Dejour D, Saffarini M, Demey G, Baverel L (2015) Tibial slope correction combined with second revision ACL produces good knee stability and prevents graft rupture. Knee Surg Sports Traumatol Arthrosc 23:2846–2852

    Article  Google Scholar 

  7. Grassi A, Macchiarola L, Lucidi GA, Stefanelli F, Neri M, Silvestri A, Della Villa F, Zaffagnini S (2020) More than a 2-fold risk of contralateral anterior cruciate ligament injuries compared with ipsilateral graft failure 10 years after primary reconstruction. Am J Sports Med 48:310–317

    Article  Google Scholar 

  8. Grassi A, Macchiarola L, Urrizola Barrientos F, Zicaro JP, Costa Paz M, Adravanti P, Dini F, Zaffagnini S (2019) Steep posterior tibial slope, anterior tibial subluxation, deep posterior lateral femoral condyle, and meniscal deficiency are common findings in multiple anterior cruciate ligament failures: an MRI case-control study. Am J Sports Med 47:285–295

    Article  Google Scholar 

  9. Grassi A, Signorelli C, Urrizola F, Macchiarola L, Raggi F, Mosca M, Samuelsson K, Zaffagnini S (2019) Patients with failed anterior cruciate ligament reconstruction have an increased posterior lateral tibial plateau slope: a case-controlled study. Arthroscopy 35:1172–1182

    Article  Google Scholar 

  10. Hamrin Senorski E, Seil R, Svantesson E, Feller JA, Webster KE, Engebretsen L, Spindler K, Siebold R, Karlsson J, Samuelsson K (2018) “I never made it to the pros…” Return to sport and becoming an elite athlete after pediatric and adolescent anterior cruciate ligament injury—current evidence and future directions. Knee Surg Sports Traumatol Arthrosc 26:1011–1018

    Article  Google Scholar 

  11. Hohmann E, Bryant A, Reaburn P, Tetsworth K (2010) Does posterior tibial slope influence knee functionality in the anterior cruciate ligament-deficient and anterior cruciate ligament-reconstructed knee? Arthroscopy 26:1496–1502

    Article  Google Scholar 

  12. LaPrade RF (2019) Steeper tibial slopes, like steeper ski slopes, might lead to more ACL stress and tears: Commentary on an article by Dean Wang, MD, et al.: “Tibiofemoral Kinematics During Compressive Loading of the ACL-Intact and ACL-Sectioned Knee. Roles of Tibial Slope, Medial Eminence Volume, and Anterior Laxity”. J Bone Jt Surg Am 101:e58

    Article  Google Scholar 

  13. Lee CC, Youm YS, Cho SD, Jung SH, Bae MH, Park SJ, Kim HW (2018) Does posterior tibial slope affect graft rupture following anterior cruciate ligament reconstruction? Arthroscopy 34:2152–2155

    Article  Google Scholar 

  14. Lind M, Menhert F, Pedersen AB (2012) Incidence and outcome after revision anterior cruciate ligament reconstruction: results from the danish registry for knee ligament reconstructions. Am J Sports Med 40:1551–1557

    Article  Google Scholar 

  15. Marouane H, Shirazi-Adl A, Adouni M, Hashemi J (2014) Steeper posterior tibial slope markedly increases ACL force in both active gait and passive knee joint under compression. J Biomech 47:1353–1359

    Article  CAS  Google Scholar 

  16. McLean SG, Oh YK, Palmer ML, Lucey SM, Lucarelli DG, Ashton-Miller JA, Wojtys EM (2011) The relationship between anterior tibial acceleration, tibial slope, and ACL strain during a simulated jump landing task. J Bone Jt Surg Am 93:1310–1317

    Article  Google Scholar 

  17. Mitchell JJ, Cinque ME, Dornan GJ, Matheny LM, Dean CS, Kruckeberg B, Moatshe G, Chahla J, LaPrade RF (2018) Primary versus revision anterior cruciate ligament reconstruction: patient demographics, radiographic findings, and associated lesions. Arthroscopy 34:695–703

    Article  Google Scholar 

  18. Napier RJ, Garcia E, Devitt BM, Feller JA, Webster KE (2019) Increased radiographic posterior tibial slope is associated with subsequent injury following revision anterior cruciate ligament reconstruction. Orthop J Sports Med. https://doi.org/10.1177/2325967119879373

    Article  PubMed  PubMed Central  Google Scholar 

  19. Rahnemai-Azar AA, Yaseen Z, van Eck CF, Irrgang JJ, Fu FH, Musahl V (2016) Increased lateral tibial plateau slope predisposes male college football players to anterior cruciate ligament injury. J Bone Jt Surg Am 98:1001–1006

    Article  Google Scholar 

  20. Roberti di Sarsina T, Macchiarola L, Signorelli C, Grassi A, Raggi F, Marcheggiani Muccioli GM, Zaffagnini S (2019) Anterior cruciate ligament reconstruction with an all-epiphyseal “over-the-top” technique is safe and shows low rate of failure in skeletally immature athletes. Knee Surg Sports Traumatol Arthrosc 27:498–506

    Article  Google Scholar 

  21. Salmon LJ, Heath E, Akrawi H, Roe JP, Linklater J, Pinczewski LA (2018) 20-Year outcomes of anterior cruciate ligament reconstruction with hamstring tendon autograft: the catastrophic effect of age and posterior tibial slope. Am J Sports Med 46:531–543

    Article  Google Scholar 

  22. Seil R, Chotel F, Robert H (2019) Collaborative efforts are needed to gain new knowledge on pediatric and adolescent anterior cruciate ligament (ACL) injuries. Orthop Traumatol Surg Res 105:1033–1035

    Article  Google Scholar 

  23. Shao Q, MacLeod TD, Manal K, Buchanan TS (2011) Estimation of ligament loading and anterior tibial translation in healthy and ACL-deficient knees during gait and the influence of increasing tibial slope using EMG-driven approach. Ann Biomed Eng 39:110–121

    Article  Google Scholar 

  24. Shelbourne KD, Gray T, Haro M (2009) Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med 37:246–251

    Article  Google Scholar 

  25. Sonnery-Cottet B, Archbold P, Cucurulo T, Fayard J-M, Bortolletto J, Thaunat M, Prost T, Chambat P (2011) The influence of the tibial slope and the size of the intercondylar notch on rupture of the anterior cruciate ligament. J Bone Jt Surg Br 93:1475–1478

    Article  CAS  Google Scholar 

  26. Sonnery-Cottet B, Mogos S, Thaunat M, Archbold P, Fayard J-M, Freychet B, Clechet J, Chambat P (2014) Proximal tibial anterior closing wedge osteotomy in repeat revision of anterior cruciate ligament reconstruction. Am J Sports Med 42:1873–1880

    Article  Google Scholar 

  27. Su AW, Bogunovic L, Smith MV, Gortz S, Brophy RH, Wright RW, Matava MJ (2020) Medial tibial slope determined by plain radiography is not associated with primary or recurrent anterior cruciate ligament tears. J Knee Surg 33:22–28

    Article  Google Scholar 

  28. Svantesson E, Hamrin Senorski E, Alentorn-Geli E, Westin O, Sundemo D, Grassi A, Čustović S, Samuelsson K (2019) Increased risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19,457 patients from the Swedish National Knee Ligament Registry. Knee Surg Sports Traumatol Arthrosc 27:2450–2459

    Article  Google Scholar 

  29. Swets JA (1988) Measuring the accuracy of diagnostic systems. Science 240:1285–1293. https://doi.org/10.1126/science.3287615

    Article  CAS  PubMed  Google Scholar 

  30. Tavakol M, Dennick R (2011) Making sense of Cronbach’s alpha. Int J Med Educ 2:53–55

    Article  Google Scholar 

  31. Thompson SM, Salmon LJ, Waller A, Linklater J, Roe JP, Pinczewski LA (2016) Twenty-year outcome of a longitudinal prospective evaluation of isolated endoscopic anterior cruciate ligament reconstruction with patellar tendon or hamstring autograft. Am J Sports Med 44:3083–3094

    Article  Google Scholar 

  32. Utzschneider S, Goettinger M, Weber P, Horng A, Glaser C, Jansson V, Müller PE (2011) Development and validation of a new method for the radiologic measurement of the tibial slope. Knee Surg Sports Traumatol Arthrosc 19:1643–1648

    Article  CAS  Google Scholar 

  33. Vyas S, van Eck CF, Vyas N, Fu FH, Otsuka NY (2011) Increased medial tibial slope in teenage pediatric population with open physes and anterior cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc 19:372–377

    Article  Google Scholar 

  34. Webb JM, Salmon LJ, Leclerc E, Pinczewski LA, Roe JP (2013) Posterior tibial slope and further anterior cruciate ligament injuries in the anterior cruciate ligament-reconstructed patient. Am J Sports Med 41:2800–2804

    Article  Google Scholar 

  35. Webster KE, Feller JA (2016) Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med 44:2827–2832

    Article  Google Scholar 

  36. Webster KE, Feller JA, Kimp AJ, Whitehead TS (2018) Revision anterior cruciate ligament reconstruction outcomes in younger patients: medial meniscal pathology and high rates of return to sport are associated with third ACL injuries. Am J Sports Med 46:1137–1142

    Article  Google Scholar 

  37. Webster KE, Feller JA, Leigh WB, Richmond AK (2014) Younger patients are at increased risk for graft rupture and contralateral injury after anterior cruciate ligament reconstruction. Am J Sports Med 42:641–647

    Article  Google Scholar 

  38. Wilson PL, Wyatt CW, Wagner KJ, Boes N, Sabatino MJ, Ellis HB (2019) Combined transphyseal and lateral extra-articular pediatric anterior cruciate ligament reconstruction: a novel technique to reduce ACL reinjury while allowing for growth. Am J Sports Med 47:3356–3364

    Article  Google Scholar 

  39. Wright RW, Dunn WR, Amendola A, Andrish JT, Bergfeld J, Kaeding CC, Marx RG, McCarty EC, Parker RD, Wolcott M, Wolf BR, Spindler KP (2007) Risk of tearing the intact anterior cruciate ligament in the contralateral knee and rupturing the anterior cruciate ligament graft during the first 2 years after anterior cruciate ligament reconstruction: a prospective MOON cohort study. Am J Sports Med 35:1131–1134

    Article  Google Scholar 

  40. Zaffagnini S, Marcheggiani Muccioli GM, Grassi A, Roberti di Sarsina T, Raggi F, Signorelli C, Urrizola F, Spinnato P, Rimondi E, Marcacci M (2017) Over-the-top ACL reconstruction plus extra-articular lateral tenodesis with hamstring tendon grafts: prospective evaluation with 20-year minimum follow-up. Am J Sports Med 45:3233–3242

    Article  Google Scholar 

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Authors and Affiliations

  1. Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, via Pupilli 1, 40136, Bologna, BO, Italy

    Alberto Grassi, Nicola Pizza, Jacopo Zambon Bertoja, Luca Macchiarola, Gian Andrea Lucidi, Giacomo Dal Fabbro & Stefano Zaffagnini

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  1. Alberto Grassi
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  2. Nicola Pizza
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  3. Jacopo Zambon Bertoja
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  4. Luca Macchiarola
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Correspondence to Nicola Pizza.

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No funding was used for the present study.

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This study obtained the approval of the IRB of the Rizzoli Orthopaedic Institute (ID: 0005169 May 07, 2019).

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Grassi, A., Pizza, N., Zambon Bertoja, J. et al. Higher risk of contralateral anterior cruciate ligament (ACL) injury within 2 years after ACL reconstruction in under-18-year-old patients with steep tibial plateau slope. Knee Surg Sports Traumatol Arthrosc 29, 1690–1700 (2021). https://doi.org/10.1007/s00167-020-06195-y

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