Influence of Preoperative Flatfoot Parameters on Anatomical Double-Bundle ACL Reconstruction Graft Failure in Teenagers.

Influence of Preoperative Flatfoot Parameters on Anatomical Double-Bundle ACL Reconstruction Graft Failure in Teenagers.

Yuko Takeuchi, MD, JAPAN Ryosuke Kawai, MD, JAPAN Hideki Hiraiwa, MD, PhD, JAPAN Takashi Tsukahara, MD, PhD, JAPAN

Department of Orthopedic Surgery, Asahi University Hospital, gifu, JAPAN


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Anatomic Location

Anatomic Structure

Diagnosis / Condition

Treatment / Technique

Ligaments

ACL

Diagnosis Method


Summary: A lower preoperative calcaneal pitch angle on the uninjured side was significantly associated with the risk of noncontact secondary ACL injury in teenage athletes.


Purpose

This study aimed to investigate the association between preoperative flatfoot-related parameters and the risk of noncontact secondary injury in teenage athletes following primary anatomical double-bundle anterior cruciate ligament reconstruction (DB-ACLR).

Methods

This retrospective study included teenage patients who underwent primary DB-ACLR at our institution between 2016 and 2022, with a minimum follow-up period of 24 months. Teenagers were defined as individuals aged 15 to 19 years. Inclusion criteria were a self-reported intention to return to the same sport and a pre-injury Tegner activity score greater than 6.
Preoperative foot parameters—calcaneal pitch (CP) angle, lateral talo-first metatarsal (LTM) angle, and cuboid height from the ground (CH)—were measured using weight-bearing lateral radiograph of each foot. Based on the median value of each parameter, patients were categorized into two groups: those with a relatively flatter foot profile (Group F) and those without (Group C).
Associations between baseline categories and demographic/clinical characteristics were evaluated using the Mann-Whitney U test for continuous variables and Fisher’s exact test for categorical variables. The association between flatfoot grouping and secondary injury occurrence was also assessed using Fisher’s exact test. A p-value < .05 was considered statistically significant.

Results

A total of 152 patients (52 males and 100 females) met the inclusion criteria. Among them, 24 patients experienced a noncontact secondary ACL injury (16 ipsilateral and 8 contralateral).
The median CP angle, LTM angle, and CH on the injured side were 18.5° [16.5–21.5], 5.5° [3.1–8.5], and 16.4 mm [13.9–18.9], respectively. On the uninjured side, the median CP angle was 19.1° [16.9–22.2], the LTM angle was 5.4° [3.1–8.6], and the CH was 16.8 mm [14.0–19.1].
For the injured foot, the secondary injury rates were comparable between Group F and Group C across all parameters: CP angle (p = 1.00), LTM angle (p = 0.82), and CH (p = 0.83).
For the uninjured foot, Group F—based on CP angle—demonstrated a significantly higher secondary injury rate (17 of 75; 23%) compared to Group C (7 of 77; 9%) (p = 0.03). For the LTM angle, Group F showed a higher, though not statistically significant, secondary injury rate (15 of 75; 20%) compared to Group C (7 of 77; 12%) (p = 0.19). For CH, the secondary injury rate was comparable between Group F (13 of 73; 18%) and Group C (13 of 79; 14%) (p = 0.51).

Conclusions

This study suggests that a lower preoperative calcaneal pitch angle on the uninjured side may be associated with an increased risk of noncontact secondary injury following ACL reconstruction in teenage athletes. Level of Evidence: Level III, retrospective prognostic trial.