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J Knee Surg 2020; 33(01): 022-028
DOI: 10.1055/s-0038-1676456
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Medial Tibial Slope Determined by Plain Radiography Is Not Associated with Primary or Recurrent Anterior Cruciate Ligament Tears

Alvin W. Su
1   Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
,
Ljiljana Bogunovic
1   Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
,
Matthew V. Smith
1   Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
,
Simon Gortz
1   Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
,
Robert H. Brophy
1   Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
,
Rick W. Wright
1   Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
,
Matthew J. Matava
1   Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
› Author Affiliations
Further Information

Publication History

09 July 2018

28 October 2018

Publication Date:
21 December 2018 (online)

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Abstract

Increased tibial slope may be associated with anterior cruciate ligament (ACL) injuries, although potential confounding effects from various patient characteristics and radiographic quantification methods have not been rigorously studied. The association of the slope of the lateral plateau with recurrent ACL injury after primary ACL reconstruction has recently been reported, but the role of medial slope is less well defined. The purpose of this study was to (1) assess medial tibial slope measurement reliability among examiners, (2) compare medial tibial slope values between patients undergoing primary ACL reconstruction, reinjured patients undergoing revision ACL reconstruction, and a control cohort with an intact ACL, (3) analyze if the medial tibial slope is an independent risk factor for noncontact ACL injury, and (4) assess how different anatomical references affect medial tibial slope values. A total of 206 patients were enrolled into one of three groups: (1) ACL-intact controls (CONTROL, n = 83), (2) first-time ACL-injured patients (PRIMARY, n = 77), and (3) patients undergoing revision ACL reconstruction (REVISION, n = 46). Three fellowship-trained sports medicine surgeons performed repeated measurements of plain lateral radiographs. The medial tibial slope was determined by three anatomical references: anterior tibial cortex (anterior tibial slope [ATS]), posterior tibial cortex (posterior tibial slope [PTS]), and the anatomical long axis of the tibia (composite tibial slope [CTS]). Substantial intra- and interobserver reliabilities were established by the intraclass correlation coefficient of 0.73 to 0.89. There was no difference in CTS, ATS, or PTS comparing the CONTROL, PRIMARY, and REVISION groups upon univariate analyses. Multivariable logistic regression model showed that none of the slope values was independently associated with ACL injury. The mean ATS for all 206 subjects was 4 and 8 degrees greater than the mean CTS and PTS, respectively. ATS correlated only moderately to PTS. We concluded that medial tibial slope measured on radiographs is not associated with primary or recurrent ACL injury, and has substantial variation and suboptimal correlation when using different anatomical references despite good inter- and intraobserver reliabilities.

Keywords

anterior cruciate ligament - ACL injury - revision ACL - knee biomechanics - tibial slope

Note

Investigation was performed at the Washington University in St. Louis. The present study was approved by the IRB #201412070.


 

  • References

  • 1 Vyas S, van Eck CF, Vyas N, Fu FH, Otsuka NY. Increased medial tibial slope in teenage pediatric population with open physes and anterior cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc 2011; 19 (03) 372-377
    CrossrefPubMedGoogle Scholar
  • 2 Hashemi J, Chandrashekar N, Mansouri H. , et al. Shallow medial tibial plateau and steep medial and lateral tibial slopes: new risk factors for anterior cruciate ligament injuries. Am J Sports Med 2010; 38 (01) 54-62
    CrossrefPubMedGoogle Scholar
  • 3 Hohmann E, Bryant A, Reaburn P, Tetsworth K. Is there a correlation between posterior tibial slope and non-contact anterior cruciate ligament injuries?. Knee Surg Sports Traumatol Arthrosc 2011; 19 (Suppl. 01) S109-S114
    CrossrefPubMedGoogle Scholar
  • 4 Brandon ML, Haynes PT, Bonamo JR, Flynn MI, Barrett GR, Sherman MF. The association between posterior-inferior tibial slope and anterior cruciate ligament insufficiency. Arthroscopy 2006; 22 (08) 894-899
    CrossrefPubMedGoogle Scholar
  • 5 Todd MS, Lalliss S, Garcia E, DeBerardino TM, Cameron KL. The relationship between posterior tibial slope and anterior cruciate ligament injuries. Am J Sports Med 2010; 38 (01) 63-67
    CrossrefPubMedGoogle Scholar
  • 6 Sonnery-Cottet B, Archbold P, Cucurulo T. , et al. The influence of the tibial slope and the size of the intercondylar notch on rupture of the anterior cruciate ligament. J Bone Joint Surg Br 2011; 93 (11) 1475-1478
    PubMedGoogle Scholar
  • 7 Bisson LJ, Gurske-DePerio J. Axial and sagittal knee geometry as a risk factor for noncontact anterior cruciate ligament tear: a case-control study. Arthroscopy 2010; 26 (07) 901-906
    CrossrefPubMedGoogle Scholar
  • 8 Dare DM, Fabricant PD, McCarthy MM. , et al. 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 2015; 43 (07) 1632-1639
    CrossrefPubMedGoogle Scholar
  • 9 Rahnemai-Azar AA, Yaseen Z, van Eck CF, Irrgang JJ, Fu FH, Musahl V. Increased lateral tibial plateau slope predisposes male college football players to anterior cruciate ligament injury. J Bone Joint Surg Am 2016; 98 (12) 1001-1006
    CrossrefPubMedGoogle Scholar
  • 10 Beynnon BD, Hall JS, Sturnick DR. , et al. Increased slope of the lateral tibial plateau subchondral bone is associated with greater risk of noncontact ACL injury in females but not in males: a prospective cohort study with a nested, matched case-control analysis. Am J Sports Med 2014; 42 (05) 1039-1048
    CrossrefPubMedGoogle Scholar
  • 11 Simon RA, Everhart JS, Nagaraja HN, Chaudhari AM. A case-control study of anterior cruciate ligament volume, tibial plateau slopes and intercondylar notch dimensions in ACL-injured knees. J Biomech 2010; 43 (09) 1702-1707
    CrossrefPubMedGoogle Scholar
  • 12 Stijak L, Herzog RF, Schai P. Is there an influence of the tibial slope of the lateral condyle on the ACL lesion? A case-control study. Knee Surg Sports Traumatol Arthrosc 2008; 16 (02) 112-117
    CrossrefPubMedGoogle Scholar
  • 13 Wordeman SC, Quatman CE, Kaeding CC, Hewett TE. In vivo evidence for tibial plateau slope as a risk factor for anterior cruciate ligament injury: a systematic review and meta-analysis. Am J Sports Med 2012; 40 (07) 1673-1681
    CrossrefPubMedGoogle Scholar
  • 14 Rahnemai-Azar AA, Abebe ES, Johnson P. , et al. Increased lateral tibial slope predicts high-grade rotatory knee laxity pre-operatively in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25 (04) 1170-1176
    CrossrefPubMedGoogle Scholar
  • 15 Christensen JJ, Krych AJ, Engasser WM, Vanhees MK, Collins MS, Dahm DL. Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. Am J Sports Med 2015; 43 (10) 2510-2514
    CrossrefPubMedGoogle Scholar
  • 16 Levins JG, Sturnick DR, Argentieri EC. , et al. Geometric risk factors associated with noncontact anterior cruciate ligament graft rupture. Am J Sports Med 2016; 44 (10) 2537-2545
    CrossrefPubMedGoogle Scholar
  • 17 Dejour D, Saffarini M, Demey G, Baverel L. Tibial slope correction combined with second revision ACL produces good knee stability and prevents graft rupture. Knee Surg Sports Traumatol Arthrosc 2015; 23 (10) 2846-2852
    CrossrefPubMedGoogle Scholar
  • 18 Sonnery-Cottet B, Mogos S, Thaunat M. , et al. Proximal tibial anterior closing wedge osteotomy in repeat revision of anterior cruciate ligament reconstruction. Am J Sports Med 2014; 42 (08) 1873-1880
    CrossrefPubMedGoogle Scholar
  • 19 Lynch TS, Parker RD, Patel RM. , et al; MOON Group. The impact of the Multicenter Orthopaedic Outcomes Network (MOON) research on anterior cruciate ligament reconstruction and orthopaedic practice. J Am Acad Orthop Surg 2015; 23 (03) 154-163
    CrossrefPubMedGoogle Scholar
  • 20 Group M, Group M. ; MARS Group. Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the Multicenter ACL Revision Study (MARS) cohort. Am J Sports Med 2014; 42 (10) 2301-2310
    CrossrefPubMedGoogle Scholar
  • 21 Utzschneider S, Goettinger M, Weber P. , et al. Development and validation of a new method for the radiologic measurement of the tibial slope. Knee Surg Sports Traumatol Arthrosc 2011; 19 (10) 1643-1648
    CrossrefPubMedGoogle Scholar
  • 22 Hohmann E, Bryant A, Reaburn P, Tetsworth K. Does posterior tibial slope influence knee functionality in the anterior cruciate ligament-deficient and anterior cruciate ligament-reconstructed knee?. Arthroscopy 2010; 26 (11) 1496-1502
    CrossrefPubMedGoogle Scholar
  • 23 Hudek R, Schmutz S, Regenfelder F, Fuchs B, Koch PP. Novel measurement technique of the tibial slope on conventional MRI. Clin Orthop Relat Res 2009; 467 (08) 2066-2072
    CrossrefPubMedGoogle Scholar
  • 24 Terauchi M, Hatayama K, Yanagisawa S, Saito K, Takagishi K. Sagittal alignment of the knee and its relationship to noncontact anterior cruciate ligament injuries. Am J Sports Med 2011; 39 (05) 1090-1094
    CrossrefPubMedGoogle Scholar
  • 25 Beynnon BD, Vacek PM, Sturnick DR. , et al. Geometric profile of the tibial plateau cartilage surface is associated with the risk of non-contact anterior cruciate ligament injury. J Orthop Res 2014; 32 (01) 61-68
    CrossrefPubMedGoogle Scholar
  • 26 Gornitzky AL, Lott A, Yellin JL, Fabricant PD, Lawrence JT, Ganley TJ. Sport-specific yearly risk and incidence of anterior cruciate ligament tears in high school athletes: a systematic review and meta-analysis. Am J Sports Med 2016; 44 (10) 2716-2723
    CrossrefPubMedGoogle Scholar
  • 27 Beynnon BD, Vacek PM, Newell MK. , et al. The effects of level of competition, sport, and sex on the incidence of first-time noncontact anterior cruciate ligament injury. Am J Sports Med 2014; 42 (08) 1806-1812
    CrossrefPubMedGoogle Scholar
  • 28 Zazulak B, Cholewicki J, Reeves NP. Neuromuscular control of trunk stability: clinical implications for sports injury prevention. J Am Acad Orthop Surg 2008; 16 (09) 497-505
    CrossrefPubMedGoogle Scholar
  • 29 Zazulak BT, Hewett TE, Reeves NP, Goldberg B, Cholewicki J. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. Am J Sports Med 2007; 35 (07) 1123-1130
    CrossrefPubMedGoogle Scholar
  • 30 Mandelbaum BR, Silvers HJ, Watanabe DS. , et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med 2005; 33 (07) 1003-1010
    CrossrefPubMedGoogle Scholar
  • 31 Hewett TE, Myer GD, Ford KR. , et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med 2005; 33 (04) 492-501
    CrossrefPubMedGoogle Scholar
  • 32 Weinberg DS, Williamson DF, Gebhart JJ, Knapik DM, Voos JE. Differences in medial and lateral posterior tibial slope: an osteological review of 1090 tibiae comparing age, sex, and race. Am J Sports Med 2017; 45 (01) 106-113
    CrossrefPubMedGoogle Scholar
  • 33 Marouane H, Shirazi-Adl A, Hashemi J. Quantification of the role of tibial posterior slope in knee joint mechanics and ACL force in simulated gait. J Biomech 2015; 48 (10) 1899-1905
    CrossrefPubMedGoogle Scholar
  • 34 Dejour H, Bonnin M. Tibial translation after anterior cruciate ligament rupture. Two radiological tests compared. J Bone Joint Surg Br 1994; 76 (05) 745-749
    PubMedGoogle Scholar
  • 35 Liu W, Maitland ME. Influence of anthropometric and mechanical variations on functional instability in the ACL-deficient knee. Ann Biomed Eng 2003; 31 (10) 1153-1161
    CrossrefPubMedGoogle Scholar
  • 36 Shao Q, MacLeod TD, Manal K, Buchanan TS. 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 2011; 39 (01) 110-121
    CrossrefPubMedGoogle Scholar
  • 37 Shelburne KB, Kim HJ, Sterett WI, Pandy MG. Effect of posterior tibial slope on knee biomechanics during functional activity. J Orthop Res 2011; 29 (02) 223-231
    CrossrefPubMedGoogle Scholar
  • 38 Fleming BC, Renstrom PA, Beynnon BD. , et al. The effect of weightbearing and external loading on anterior cruciate ligament strain. J Biomech 2001; 34 (02) 163-170
    CrossrefPubMedGoogle Scholar
  • 39 Markolf KL, Jackson SR, Foster B, McAllister DR. ACL forces and knee kinematics produced by axial tibial compression during a passive flexion-extension cycle. J Orthop Res 2014; 32 (01) 89-95
    CrossrefPubMedGoogle Scholar
  • 40 Giffin JR, Vogrin TM, Zantop T, Woo SL, Harner CD. Effects of increasing tibial slope on the biomechanics of the knee. Am J Sports Med 2004; 32 (02) 376-382
    CrossrefPubMedGoogle Scholar
  • 41 Nelitz M, Seitz AM, Bauer J, Reichel H, Ignatius A, Dürselen L. Increasing posterior tibial slope does not raise anterior cruciate ligament strain but decreases tibial rotation ability. Clin Biomech (Bristol, Avon) 2013; 28 (03) 285-290
    CrossrefPubMedGoogle Scholar
  • 42 Fening SD, Kovacic J, Kambic H, McLean S, Scott J, Miniaci A. The effects of modified posterior tibial slope on anterior cruciate ligament strain and knee kinematics: a human cadaveric study. J Knee Surg 2008; 21 (03) 205-211
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Dean CS, Chahla J, Matheny LM. , et al. Posteromedially placed plates with anterior staple reinforcement are not successful in decreasing tibial slope in opening-wedge proximal tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2017; 25 (12) 3687-3694
    CrossrefPubMedGoogle Scholar