Both tibial spine fractures (TSFs) and anterior cruciate ligament (ACL) tears result in functional loss of knee stability. Nonetheless, it remains unclear why some patients sustain ACL tears, whereas others have TSFs.
Purpose:
To identify the common morphological risk factors for pediatric ACL tears and TSFs and to determine the morphological differences between them using multiplanar reconstruction of magnetic resonance imaging (MRI).
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Age- and sex-matched participants (159 total [53 ACL tears, 53 TSFs, and 53 controls]) aged <18 years who visited a pediatric tertiary-care center for ACL tears, TSFs, or anterior knee pain from March 2009 to April 2023 were included. Each group comprised 41 male and 12 female participants. Data on demographic characteristics and estimated bone age based on the knee MRI atlas were retrospectively collected, and various knee morphological parameters were evaluated using multiplanar reconstruction of MRI. Parameters showing significant differences among the 3 groups were selected as independent variables for multivariable multinomial logistic regression analysis, with the groups as dependent variables.
Results:
The mean chronological age at the time of MRI was 13.2 ± 2.3 years. Height, weight, body mass index, bone age, articular medial tibial slope, and bony medial tibial slope did not differ among the groups. Articular lateral tibial slope was independently associated with the occurrence of both ACL tears (relative risk ratio [RRR], 1.42 [95% confidence interval (CI), 1.16-1.74]; P = .001) and TSFs (RRR, 1.33 [95% CI, 1.10-1.62]; P = .004). A high notch width index was a protective factor against ACL tears (RRR, 0.86 [95% CI, 0.77-0.96]; P = .006) but not against TSFs (RRR, 1.01 [95% CI, 0.91-1.12]; P = .848).
Conclusion:
A high articular lateral tibial slope was a common risk factor for ACL tears and TSFs. Patients with ACL tears had a narrower intercondylar notch than those with TSFs and controls.
AcevedoRJRivera-VegaAMirandaGMicheoW.Anterior cruciate ligament injury: identification of risk factors and prevention strategies. Curr Sports Med Rep. 2014;13(3):186-191.
2.
AkcaalanSKavaklilarACaglarC, et al. Investigation of morphometric factors associated with adolescent ACL rupture. Orthop J Sports Med. 2023;11(9):23259671231194928.
3.
AlbertsonBBeynnonBEndresNJohnsonR.Incidence of anterior tibial spine fracture among skiers does not differ with age. Knee Surg Sports Traumatol Arthrosc. 2022;30(7):2291-2297.
4.
Alentorn-GeliEPelfortXMingoF, et al. An evaluation of the association between radiographic intercondylar notch narrowing and anterior cruciate ligament injury in men: the notch angle is a better parameter than notch width. Arthroscopy. 2015;31(10):2004-2013.
5.
BarnumMSBoydEDVacekPSlauterbeckJRBeynnonBD.Association of geometric characteristics of knee anatomy (alpha angle and intercondylar notch type) with noncontact ACL injury. Am J Sports Med. 2021;49(10):2624-2630.
6.
BeynnonBDHallJSSturnickDR, 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(5):1039-1048.
7.
BogunovicLTarabichiMHarrisDWrightR.Treatment of tibial eminence fractures: a systematic review. J Knee Surg. 2015;28(3):255-262.
8.
BrodeurPGLichtAHModestJM, et al. Epidemiology and revision rates of pediatric ACL reconstruction in New York State. Am J Sports Med. 2022;50(5):1222-1228.
9.
ButlerDLNoyesFRGroodES.Ligamentous restraints to anterior-posterior drawer in the human knee: a biomechanical study. J Bone Joint Surg Am. 1980;62(2):259-270.
10.
ChaudhariAMZelmanEAFlaniganDCKaedingCCNagarajaHN.Anterior cruciate ligament-injured subjects have smaller anterior cruciate ligaments than matched controls: a magnetic resonance imaging study. Am J Sports Med. 2009;37(7):1282-1287.
11.
DareDMFabricantPDMcCarthyMM, 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(7):1632-1639.
12.
DejourHBonninM.Tibial translation after anterior cruciate ligament rupture: two radiological tests compared. J Bone Joint Surg Br. 1994;76(5):745-749.
13.
DietvorstMvan der SteenMCMReijmanMJanssenRPA. Diagnostic values of history taking, physical examination and KT-1000 arthrometer for suspect anterior cruciate ligament injuries in children and adolescents: a prospective diagnostic study. BMC Musculoskelet Disord. 2022;23(1):710.
14.
DragooJLCastilloTNBraunHJ, et al. Prospective correlation between serum relaxin concentration and anterior cruciate ligament tears among elite collegiate female athletes. Am J Sports Med. 2011;39(10):2175-2180.
15.
EdwardsTCNaqviAZDela CruzNGupteCM.Predictors of pediatric anterior cruciate ligament injury: the influence of steep lateral posterior tibial slope and its relationship to the lateral meniscus. Arthroscopy. 2021;37(5):1599-1609.
16.
Fernández-JaénTLópez-AlcorochoJMRodriguez-IñigoE, et al. The importance of the intercondylar notch in anterior cruciate ligament tears. Orthop J Sports Med. 2015;3(8):2325967115597882.
17.
FleissJL. Reliability of measurement. In: FleissJL, ed. Design and Analysis of Clinical Experiments. 1st ed.John Wiley & Sons; 1986:1-32.
18.
FreitasEVPerezMKJimenezAE, et al. Higher meniscal slope is a risk factor for anterior cruciate ligament injury in skeletally immature patients. Arthroscopy. 2021;37(8):2582-2588.
19.
GaudianiMACooperTDrummondAHansenLMTompkinsMA.Guided growth for correction of elevated tibial posterior slope in pediatric ACL deficiency: a case report. JBJS Case Connect. 2024;14(4):e24.00188.
20.
HashemiJChandrashekarNMansouriH, 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(1):54-62.
21.
HeMLiJ.Increased lateral femoral condyle ratio measured by MRI is associated with higher risk of noncontact anterior cruciate ligament injury. BMC Musculoskelet Disord. 2022;23(1):190.
22.
HerzogMMMarshallSWLundJL, et al. Incidence of anterior cruciate ligament reconstruction among adolescent females in the United States, 2002 through 2014. JAMA Pediatr. 2017;171(8):808-810.
23.
KızılgözVSivrioğluAKUlusoyGR, et al. Analysis of the risk factors for anterior cruciate ligament injury: an investigation of structural tendencies. Clin Imaging. 2018;50:20-30.
24.
KocherMSGanleyTJ. Sports medicine in the growing child. In: WeinsteinSLFlynnJMCrawfordHA, eds. Lovell and Winter’s Pediatric Orthopaedics. Vol 2. 8th ed.Lippincott Williams & Wilkins; 2020:1537-1600.
25.
KocherMSMandigaRKlingeleKBleyLMicheliLJ.Anterior cruciate ligament injury versus tibial spine fracture in the skeletally immature knee: a comparison of skeletal maturation and notch width index. J Pediatr Orthop. 2004;24(2):185-188.
26.
KwakYHNamJHKohYGParkBKKangKT.Anatomic differences in the sagittal knee joint are associated with ACL injury: results from a skeletally immature Korean population. Orthop J Sports Med. 2021;9(4):2325967121994795.
27.
LandisJRKochGG.The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-174.
28.
MatsuoTKoyanagiMOkimotoR, et al. Quantitative evaluation of functional instability due to anterior cruciate ligament deficiency. Orthop J Sports Med. 2020;8(7):2325967120933885.
29.
MessnerMKMcGeeASElphingstoneJW, et al. The relationship between posterior tibial slope and pediatric tibial eminence fractures. Am J Sports Med. 2023;51(1):32-37.
30.
MezaBCLaValvaSMAoyamaJT, et al. A novel shorthand approach to knee bone age using MRI: a validation and reliability study. Orthop J Sports Med. 2021;9(8):23259671211021582.
31.
MitchellBCSiowMYBastromT, et al. Coronal lateral collateral ligament sign: a novel magnetic resonance imaging sign for identifying anterior cruciate ligament-deficient knees in adolescents and summarizing the extent of anterior tibial translation and femorotibial internal rotation. Am J Sports Med. 2021;49(4):928-934.
32.
O’MalleyMPMilewskiMDSolomitoMJErwtemanASNissenCW.The association of tibial slope and anterior cruciate ligament rupture in skeletally immature patients. Arthroscopy. 2015;31(1):77-82.
33.
OrsiADCanavanPKVaziriA, et al. The effects of graft size and insertion site location during anterior cruciate ligament reconstruction on intercondylar notch impingement. Knee. 2017;24(3):525-535.
34.
PfeifferTRBurnhamJMHughesJD, et al. An increased lateral femoral condyle ratio is a risk factor for anterior cruciate ligament injury. J Bone Joint Surg Am. 2018;100(10):857-864.
35.
PradhanPKaushalSGKocherMSKiapourAM.Development of anatomic risk factors for ACL injuries: a comparison between ACL-injured knees and matched controls. Am J Sports Med. 2023;51(9):2267-2274.
36.
RetzkyJSGrossPWDoyleSMStricklandSM.High rates of abnormal patellofemoral morphology in adolescents with anterior knee pain: a retrospective review. HSS J. 2024;20(3):351-358.
37.
SamoraWBeranMCParikhSN.Intercondylar roof inclination angle: is it a risk factor for ACL tears or tibial spine fractures?J Pediatr Orthop. 2016;36(6):e71-e74.
38.
ShinCHSyedANSwansonME, et al. Evaluation of tibial slope on radiographs in pediatric patients with tibial spine fractures: an age- and sex-matched study. Orthop J Sports Med. 2024;12(7):23259671241256445.
39.
SimonRAEverhartJSNagarajaHNChaudhariAM.A case-control study of anterior cruciate ligament volume, tibial plateau slopes and intercondylar notch dimensions in ACL-injured knees. J Biomech. 2010;43(9):1702-1707.
40.
SturnickDRVacekPMDeSarnoMJ, et al. Combined anatomic factors predicting risk of anterior cruciate ligament injury for males and females. Am J Sports Med. 2015;43(4):839-847.
41.
SturnickDRVan GorderRVacekPM, et al. Tibial articular cartilage and meniscus geometries combine to influence female risk of anterior cruciate ligament injury. J Orthop Res. 2014;32(11):1487-1494.
42.
TaylorJBWaxmanJPRichterSJShultzSJ.Evaluation of the effectiveness of anterior cruciate ligament injury prevention programme training components: a systematic review and meta-analysis. Br J Sports Med. 2015;49(2):79-87.
43.
ThompsonRHamiltonDMurrayILawsonG.Notchplasty is associated with decreased risk of anterior cruciate ligament graft revision. Eur J Orthop Surg Traumatol. 2023;33(5):1533-1539.
44.
VrooijinkSHAWoltersFVan EckCFFuFH. Measurements of knee morphometrics using MRI and arthroscopy: a comparative study between ACL-injured and non-injured subjects. Knee Surg Sports Traumatol Arthrosc. 2011;19(1):12-16.
45.
VyasSvan EckCFVyasNFuFHOtsukaNY.Increased medial tibial slope in teenage pediatric population with open physes and anterior cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc. 2010;19(3):372-377.
46.
WeinbergDSWilliamsonDFKGebhartJJKnapikDMVoosJE.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(1):106-113.
47.
WhitneyDCSturnickDRVacekPM, et al. Relationship between the risk of suffering a first-time noncontact ACL injury and geometry of the femoral notch and ACL: a prospective cohort study with a nested case-control analysis. Am J Sports Med. 2014;42(8):1796-1805.
48.
ZaricznyjB.Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. J Bone Joint Surg Am. 1977;59(8):1111-1114.
49.
ZhangLXiaQYangR, et al. Anatomical factors associated with the development of anterior tibial spine fractures based on MRI measurements. J Orthop Surg Res. 2023;18(1):357.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
