The Segond fracture, an avulsion fracture of proximal anterolateral tibia, can be observed in patients with an anterior cruciate ligament (ACL) tear; however, it is unclear whether the Segond fracture affects clinical outcomes following ACL reconstruction, perhaps requiring surgical attention at the time of index reconstruction. The purpose of the present systematic review was to investigate whether the presence of a concomitant Segond fracture affects clinical outcomes following ACL reconstruction, and to compare clinical outcomes when a Segond fracture is treated with or without surgical management.
Three databases (PubMed, EMBASE, Cochrane Library) were searched in accordance with the PRISMA guidelines on July 27, 2020. Relevant studies, which reported clinical outcomes following ACL reconstruction with a concomitant Segond fracture, were screened in duplicate. Data regarding patient demographics, clinical outcomes were extracted. Quality assessment of non-randomized cohort studies and case series was performed using the Methodological Index for Non-Randomized Studies (MINORS) quality assessment tool. Descriptive statistics are presented. A meta-analysis of risk ratios using a random effects model was conducted in order to assess the incidence of graft failure in the Segond fracture group compared to the group without a Segond fracture.
A total of six studies (level of evidence; four studies, III; two studies, IV) examining 2,510 patients (1011 females, 40.3%), mean age 25.3 years, were included in this study. Of those, there were 305 patients with a Segond fracture (mean age, 28.0 years; 35.7% female) and 2,205 patients without a Segond fracture (mean age, 25.0 years; 40.9% female). Four studies directly compared clinical outcomes between patients with an unrepaired Segond fracture and no Segond fracture. One study reported 12 patients who underwent ACL reconstruction and repair of the Segond fracture, and another case series reported clinical outcomes in 92 ACL injured patients (including one Segond fracture case) who underwent combined ACL and anterolateral ligament reconstructions. Overall, in four studies, 11 of 292 (3.8%) graft failures were reported in the Segond fracture groups, while 145 of 2,114 (6.9%) graft failures were reported in the no Segond fracture groups. No significant difference was observed in the risk of graft failure between the two groups, with a risk ratio of 0.59 (95% CI = 0.32 to 1.07, p=0.08, I2=0%). No clinically significant differences were observed with regards to IKDC score, Lysholm score, Tegner activity scale, and postoperative knee laxity.
There is no evidence that an unrepaired Segond fracture has any negative effect on postoperative stability or risk of graft failure after ACL reconstruction. Future prospective studies may be warranted to confirm the finding that patients with combined ACL injury and Segond fracture may have comparable outcomes to ACL-injured patients without a Segond fracture when isolated ACL reconstruction is performed.