Measurement technique for posterior tibial slope on radiographs can affect its relationship to the risk of anterior cruciate ligament rupture

Gaj, Edoardo; Monaco, Edoardo; Carli, Angelo De; Wolf, Megan; Massafra, Carlo; Redler, Andrea; Mazza, Daniele; Ferretti, Andrea

doi:10.1007/s00264-020-04865-7

Cited by 9 publications

(10 citation statements)

References 26 publications

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“…The association between the PTS and primary ACL injuries has been shown by a number of studies that measured the PTS on radiography, comparing patients who sustained ACL injuries with those without a history of ACL injuries. 4,15,30,36,37 The biomechanical reason for the association between an increased PTS and the incidence of ACL injuries has been demonstrated in previous cadaveric studies. 16,27 Giffin et al 16 originally found an elevated PTS to be associated with increased anterior tibial translation, especially in full extension.…”

Section: Discussionmentioning

confidence: 80%

“…The variability in tibial slope measurements among different methods and imaging modalities has been investigated by several studies. 15,19,23,29 Naendrup et al 29 found that PTS measurements have a high degree of variability between measurement methods and imaging modalities, reporting a difference of up to 5° between methods. Jahn et al 23 recently found that the MPTS was larger by approximately 5° on radiography compared with MRI, with the LPTS being 2° greater on radiography.…”

Section: Discussionmentioning

confidence: 99%

“…In the current study, radiographic PTS measurements were significantly greater than both the MPTS and the LPTS on MRI by approximately 6° and 4°, respectively. Gaj et al 15 compared 3 PTS measurement techniques and found only 1 technique to be associated with ACL injuries.…”

Section: Discussionmentioning

confidence: 99%

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Posterior Tibial Slope in Patients Undergoing Bilateral Versus Unilateral ACL Reconstruction: MRI and Radiographic Analyses

Garra,

Li,

Triana

et al. 2023

Am J Sports Med

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Background: An increased posterior tibial slope (PTS) is a risk factor for primary anterior cruciate ligament (ACL) tears and graft failure, but the PTS has not been well-defined in those who have experienced bilateral ACL injuries. Purpose: The primary aim was to compare the PTS, as well as the rate of an elevated PTS (>12° on lateral radiography; >7° on magnetic resonance imaging [MRI]), between patients who have undergone bilateral ACL reconstruction (ACLR) versus unilateral ACLR. A secondary purpose was to examine whether these associations remained consistent on both plain radiography and MRI. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We retrospectively identified patients who underwent primary ACLR at our institution from the years 2012 to 2020. Patients who underwent nonsimultaneous bilateral ACLR (n = 53) were matched to those who underwent unilateral ACLR (n = 53) by age, sex, and body mass index. Exclusion criteria were rotated lateral radiographs, MRI scans of inadequate quality, and concomitant ligament injuries or fractures. Those who had undergone unilateral ACLR with <5-year follow-up were further excluded. There were 3 blinded readers who measured the PTS on lateral radiographs, while the medial PTS (MPTS) and lateral PTS (LPTS) were measured on MRI scans. Bivariate regression was performed to determine the correlation between radiographic and MRI measurements. Results: The PTS on radiography (11.26° vs 10.13°, respectively; P = .044) and the LPTS on MRI (7.32° vs 6.08°, respectively; P = .012) in the bilateral ACLR group were significantly greater than those in the unilateral ACLR group but not the MPTS on MRI (4.55° vs 4.17°, respectively; P = .590). The percentage of patients in the bilateral group with a radiographic PTS >12° was 41.0% compared with 13.2% in the unilateral group ( P = .012). The bilateral group had a significantly higher rate of an LPTS >7° compared with the unilateral group (53.8% vs 32.1%, respectively; P = .016) but not for an MPTS >7° ( P = .190). On MRI, the LPTS (6.90°± 2.73°) was significantly greater than the MPTS (4.41°± 2.92°) ( P < .001). There was a weak correlation between MPTS and radiographic PTS measurements ( R = 0.24; P = .021), but LPTS and radiographic PTS measurements were not significantly correlated ( R = 0.03; P = .810). Conclusion: Patients who underwent bilateral ACLR had a significantly greater PTS on radiography and a significantly greater LPTS on MRI compared with those who underwent unilateral ACLR. The rate of a radiographic PTS >12° was 2.4 times greater among patients undergoing bilateral ACLR compared with those undergoing unilateral ACLR. PTS measurements on radiography demonstrated a weak to negligible correlation with PTS measurements on MRI, suggesting that future normative PTS values should be reported specific to the imaging modality.

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Section: Discussionmentioning

confidence: 80%

Section: Discussionmentioning

confidence: 99%

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Posterior Tibial Slope in Patients Undergoing Bilateral Versus Unilateral ACL Reconstruction: MRI and Radiographic Analyses

Garra,

Li,

Triana

et al. 2023

Am J Sports Med

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“…Although the tibial mechanical axis is a valid reference for PTS measurement, a recent study revealed better intra- and interobserver repeatability for measurement of PTS relative to the tibial diaphyseal axes. 8 Fifth, anterior wedge heights were estimated by a simplified trigonometric relationship that only accounted for the mTP length and the absolute anterior metaphyseal height. Sixth, the findings of the present study are based on an objective analysis of proximal tibial metaphyseal anatomy, which did not account for other important factors such as patellar height, sufficient exposure of the osteotomy site, or risk of tendon damage, when considering a supratuberosity TDO.…”

Section: Discussionmentioning

confidence: 99%

“…The American Journal of Sports Medicine 2023;51 (8):2091-2097 DOI: 10.1177/03635465231175879 Ó 2023 The Author(s) ''infratuberosity'' TDO 11 is performed distal to the anterior tibial tuberosity, preserving the distal patellar tendon insertion, but could lead to nonunion due to tensile forces of the extensor mechanism. 9 ''Transtuberosity'' TDO 19 is performed at the level of the tibial tuberosity, which requires detachment of the distal patellar tendon insertion, and could thereby compromise the extensor mechanism.…”

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confidence: 99%

Sufficient Metaphyseal Bone for Wedge Removal and Fixation Hardware During Supratuberosity Tibial Deflexion Osteotomy in Knees With Excessive Posterior Tibial Slope

et al. 2023

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Background: Tibial deflexion osteotomy (TDO) is sometimes indicated for revision anterior cruciate ligament (ACL) reconstruction in knees with posterior tibial slope (PTS) ≥12° and aims to decrease PTS to around 5°. When planning TDO, measuring the anterior tibial metaphyseal height (aHt) could help ascertain whether the available metaphyseal bone would be sufficient to create the wedge and leave adequate residual bone. Purpose: To (1) determine whether, compared with knees with normal native PTS (<12°), aHt is greater in knees with excessive native PTS (≥12°), and (2) verify if, aiming to decrease PTS to 5°, supratuberosity TDO in knees with excessive native PTS could be performed without tibial tuberosity osteotomy, leaving a minimum of 15 mm of residual bone for fixation staples or plates. Study Design: Cross-sectional study; Level of evidence, 3. Methods: True lateral radiographs of 350 consecutive patients scheduled for ACL reconstruction were digitized to measure PTS, tibial medial plateau length, tibial anterior and posterior metaphyseal heights and inclinations, and patellar height. Measurements were compared between knees with PTS <12° and those with ≥12°. The wedge height required for supratuberosity TDO was estimated for knees with excessive PTS, aiming for a target PTS of 5°, to determine the proportion of knees that would have residual aHt <15 mm. Results: A total of 326 knees had adequate true lateral radiographs. The mean PTS was 9.8°± 3.1° (range, 1°-20°) and exceeded 12° in 83 (25%) knees. There were no significant differences between knees with normal versus excessive PTS when comparing aHt (30.7 ± 4.5 mm vs 31.6 ± 4.9 mm; P = .270) and medial tibial plateau length (43.1 ± 5.4 mm vs 43.3 ± 5.6 mm; P = .910). Setting the target mPTS at 5° for supratuberosity TDO, the mean residual aHt was 25.0 ± 4.4 mm, and 7 (8%) knees had a residual aHt <20 mm, of which only 1 (1%) had residual aHt <15 mm. Setting the target mPTS at 0°, the mean residual aHt was 21.3 ± 4.2 mm, and 36 (43%) knees had a residual aHt <20 mm, of which only 4 (5%) had residual aHt <15 mm. Conclusion: aHt was not significantly different between knees with normal versus excessive PTS. Estimation of the wedge height required for supratuberosity TDO to reduce excessive PTS to 5° revealed sufficient metaphyseal bone for wedge removal in all knees. Furthermore, 99% of knees would have sufficient residual bone (aHt, ≥15 mm) to accommodate fixation staples or plates, without the need for tibial tuberosity osteotomy.

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An increased posterior tibial slope is associated with a higher risk of graft failure following ACL reconstruction: a systematic review

Liu

Jiang

et al. 2022

Knee Surg Sports Traumatol Arthrosc

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PurposeThe posterior tibial slope (PTS) is considered a risk factor for anterior cruciate ligament (ACL) injury. However, the influence of PTS on graft failure following ACL reconstruction remains relatively unknown. Therefore, this systematic review was conducted to investigate whether PTS could be a potential risk factor for graft failure after ACL reconstruction. MethodsPubMed, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure Database, and Wanfang Database were comprehensively searched from inception to March 31, 2021. Observational studies reporting the associations of medial tibial plateau slope (MTPS) or lateral tibial plateau slope (LTPS) with graft failure after ACL reconstruction were evaluated. ResultsTwenty studies involving 12 case–control studies, 4 retrospective studies and 4 cross‐sectional studies including 5326 patients met the final inclusion criteria. The high heterogeneity and the characteristics of nonrandomized controlled trials limited data synthesis. Fifteen of the 20 included studies detected a significant association between increased PTS and ACL graft failure, while 5 studies concluded that increased PTS was not associated with ACL graft failure. Ten studies suggested that MTPS is associated with ACL graft failure, and six studies suggested that LTPS is associated with ACL graft failure. The mean MTPS values for nonfailure group ranged from 3.5° ± 2.5° to 14.4° ± 2.8°. For the graft failure group, MTPS ranged from 4.71° ± 2.41° to 17.2° ± 2.2°. The mean LTPS values for nonfailure group ranged from 2.9° ± 2.1° to 11.9° ± 3.0°. For the graft failure group, LTPS ranged from 5.5° ± 3.0° to 13.3° ± 3.0°. The reported PTS values that caused ACL graft failure was greater than 7.4° to 17°. ConclusionBased on the current clinical evidence, increased PTS is associated with a higher risk of ACL graft failure after ACL reconstruction. Despite various methods of measuring PTS have high reliability, there is still vast disagreement in the actual value of PTS. Level of evidenceIV.

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Measurement technique for posterior tibial slope on radiographs can affect its relationship to the risk of anterior cruciate ligament rupture

Cited by 9 publications

References 26 publications

Posterior Tibial Slope in Patients Undergoing Bilateral Versus Unilateral ACL Reconstruction: MRI and Radiographic Analyses

Posterior Tibial Slope in Patients Undergoing Bilateral Versus Unilateral ACL Reconstruction: MRI and Radiographic Analyses

Sufficient Metaphyseal Bone for Wedge Removal and Fixation Hardware During Supratuberosity Tibial Deflexion Osteotomy in Knees With Excessive Posterior Tibial Slope

An increased posterior tibial slope is associated with a higher risk of graft failure following ACL reconstruction: a systematic review

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