Purpose: This study introduces the posterior tibial plateau offset (PTO). It was hypothesised that (1) the PTO is reliably quantifiable and (2) correlates with the posterior tibial slope (PTS). Methods: The study involved lateral radiographs of patients who sustained an anterior cruciate ligament (ACL) graft failure and a control group. Exclusion criteria were skeletal immaturity, osteoarthritis (Kellgren and Lawrence grade > I), lateral radiographs with <15 cm of tibial shaft, or malrotated radiographs. The PTS was measured in both groups. The PTO was defined as the relative distance from the posterior tibial plateau to the tibial shaft axis in relation to the sagittal diameter of the tibial plateau (in%). Linear correlation assessed the PTS to PTO association. Results: A total of 146 patients (ACL graft failure, n = 103; control group, n = 43; 45% female, 60% left knees) were included. Mean overall PTO was 82% ± 7% (1%–35%), and mean PTS was 12° ± 3 (7–20). The PTS and PTO showed a moderate positive correlation in the overall collective ( r = 0.5; p < 0.001), ACL graft failure group ( r = 0.49; p < 0.001), and control group ( r = 0.69; p < 0.001), indicating a higher slope corresponded to a greater PTO. There was no statistical difference in PTO between the ACL failure and the control group (82% vs. 83%, p < 0.05). ICC between three raters was (0.8–0.9; p < 0.05). Conclusion: The PTO is a simple and repeatable measurement. A higher PTS is associated with a greater PTO, and the variability of the PTO across the patients with ACL graft failure and the control group was high. When planning osteotomy levels in the highly sloped proximal tibia, the PTO may be considered to optimise individualised planning for patients with failed ACL reconstruction. Level of Evidence: Level V.

Purpose: To assess associations between coronal knee alignment and regional epiphyseal bone mineral density (BMD) using computed tomography (CT)‐derived Hounsfield units (HU) and compare medial‐to‐lateral ratios (MLRs) across alignment groups, and as a secondary aim, to evaluate the association of sex and demographic factors with regional BMD patterns. Methods: A retrospective search (2008–2025) identified patients with non‐contrast knee CT and standing anteroposterior long‐leg radiographs. Exclusions included prior femur or tibia fracture or surgery and metabolic bone disease other than osteopenia or osteoporosis. Mean trabecular HU were measured for medial and lateral femoral condyles (MFC, LFC), distal femur epiphysis (DFE), medial and lateral tibial plateaus (MTP, LTP) and proximal tibia epiphysis (PTE). Outcomes included DFE‐MLR (MFC/LFC), PTE‐MLR (MTP/LTP) and combined‐MLR ([MFC + MTP]/[LFC + LTP]). Alignment was categorized by hip–knee–ankle angle (HKAA) as major varus, varus, neutral, valgus or major valgus. Results: The cohort included 312 patients (mean age 66.5 ± 9.3 years; 50.6% female); 99.4% underwent CT for robotic‐assisted arthroplasty planning. LFC HU exceeded MFC HU in 88.5% of cases ( p < 0.001), and MTP HU exceeded LTP HU in 92.9% ( p < 0.001). Increasing valgus correlated with decreasing MLR (DFE‐MLR r = −0.459; PTE‐MLR r = −0.322; combined‐MLR r = −0.509; all p < 0.001). Females demonstrated higher PTE‐MLR and combined‐MLR than males ( p ≤ 0.049). Conclusions: Coronal knee alignment was strongly associated with compartmental epiphyseal BMD MLR, with lower MLR in valgus alignment and greater alignment sensitivity in females. These findings provide quantitative imaging context relevant to arthroplasty planning. Level of Evidence: Level III, retrospective comparative study.

Purpose: To compare the planning precision of three wedge height planning methods relative to angular‐based reference planning for infratubercle anterior closing wedge high tibial osteotomy (ACW‐HTO). Methods: Lateral knee radiographs of patients with posterior tibial slope (PTS) ≥ 13° were retrospectively reviewed. Infratubercle ACW‐HTO was planned targeting a PTS of 5°. Angle‐based planning served as the reference. Three methods were evaluated: wedge height calculated from osteotomy depth and correction angle (osteotomy depth method), a fixed ratio of 1.2 mm per degree of correction (ratio 1), and 1.67 mm per degree (ratio 2). Correction error was defined as the difference in wedge heights between each method. Planning precision was assessed using a ±1° correction error threshold. Intraclass correlation coefficient (ICC) was assessed. Results: Forty‐six lateral knee radiographs of 46 patients (mean age 30 ± 11 years; 44% female) were included. Mean PTS was 15° ± 2° (range: 13–19°), requiring a mean correction of 10° ± 2° (range: 8–14°). Wedge heights differed significantly across planning methods ( p < 0.001). Compared to the reference, ratio 1 underestimated wedge height by −1 ± 2 mm (range: −4 to 3 mm; p = 0.024) and ratio 2 overestimated by 4 ± 2 mm (range: 1–8 mm; p = 0.005). The osteotomy depth method achieved a correction error within ±1° in 83% of cases (38/46), ratio 1 (50%, 23/46; p = 0.048) and ratio 2 (9%, 6/46; p < 0.001). Interrater ICC was 0.85 (95% confidence interval [CI]: 0.73–0.92) for PTS, 0.91 (95% CI: 0.83–0.95) for osteotomy depth and 0.89 (95% CI: 0.80–0.94) for wedge height. Conclusion: Fixed wedge height ratios resulted in a correction error greater than ±1° relative to the angular‐based method in up to 91% of infratubercle ACW‐HTOs. Wedge height calculated from osteotomy depth and correction angle provides superior planning precision. Level of Evidence: Level IV.

Background: The absence of a comprehensive classification system for Achilles tendon (AT) injuries contributes to the lack of consensus regarding optimal treatment strategies, as it hinders accurate differentiation of injury types. Purpose: To evaluate epidemiology of AT ruptures to develop a magnetic resonance imaging–based classification system for rupture location. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A search was conducted for all patients with acute AT injuries between 2016 and 2023. Tear locations were classified as follows: type 1 (musculotendinous junction; MTJ), type 1A (2-cm zone distal to MTJ), type 2 (midsubstance), type 3 (2-cm zone proximal to insertion), type 3A (soft tissue “peel-off”), type 3B (calcaneal bony avulsion). Clinicodemographic data were collected, and rupture gap size, tendon thickness, tibiotalar, and plantarflexion angle were measured. Results: A total of 428 patients were included (age 45 ± 15 years; 17% female). Mean rupture gap size was 30 ± 16 mm in 73°± 8° tibiotalar flexion. AT tear distribution: type 1, 62.7%; type 1A, 16.3%; type 2, 13.8%; type 3, 0.7%; type 3A, 5.8%; and type 3B, 0.7%. Female patients demonstrated lower tendon thickness ( P < .001) and a significantly higher prevalence of type 3, 3A, and 3B ( P < .001). Multivariate analysis revealed that proximal AT tears were associated with presence of tendinopathy (odds ratio [OR], 2.19; 95% CI, 1.24-3.83), while younger age and larger gap size were significant but with a weak effect size. Midsubstance tears were predicted by older age and increased tendon thickness (OR, 1.02-1.17). Distal tears were associated with absence of tendinopathy (OR, 0.17; 95% CI, 0.07-0.39), while age only had a small effect. Tear location measurements demonstrated substantial to almost perfect interobserver (3 observers; n = 35; Cohen's kappa = 0.93; 95% CI, 0.74-0.99) and intraobserver (1 observer; n = 35; Cohen's kappa = 0.93; 95% CI, 0.86-0.99) reliability. Conclusion: This study introduces an AT tear classification system that demonstrated substantial to almost perfect reliability. AT ruptures at the MTJ were most common (63%). Presence of tendinopathy, age, gap size, and tendon thickness were significant predictors for AT tear type. Female patients exhibited lower tendon thickness and a significantly higher prevalence of distal tear location. Studies with larger cohort sizes are necessary to confirm the current findings.

OBJECTIVES: To compare the clinical outcomes of plate fixation with and without coracoclavicular (CC) suture Endobutton augmentation in the management of displaced lateral clavicle fractures. METHODS: Design : Retrospective study. Setting: Tertiary referral hospital. Patient Selection Criteria: Included were adult patients with displaced lateral clavicle fractures (OTA/AO 15.3) who underwent plate fixation between June 2021 and April 2024. The Augmentation group received adjunctive suture Endobutton fixation, while the Control group did not. Outcome Measures and Comparisons: Clinical outcomes including union, coracoclavicular (CC) distance, infection, re-operation, and self-reported functional outcomes consisting of the Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and numerical rating scale for pain (NRSP) were evaluated and compared between the two groups. To normalize for magnification, the ratio of CC distance to midclavicular width (CCD/MCW) was used to compare the CC distance over time. RESULTS: Forty-nine patients were included, 21 in the Augmentation group (76.2% male, mean age 47.5 years) and 28 in the Control group (75% male, mean age 46.6 years). In the Augmentation group, 15 patients (71.4%) underwent dual plating and 6 (28.6%) underwent single plate fixation. In the Control group, 15 patients (53.6%) underwent dual plating, 10 (35.7%) underwent single plate fixation, and 3 (10.7%) underwent hook plate fixation. The mean study follow-up was 33.7 months (range 4.2-118.6). Union was achieved in all patients (100%) in the Augmentation group, compared to 92.8% in the Control group (p = 0.19). Preoperative CCD/MCW ratios were 2.6 for the Augmentation group and 2.3 for the Control group (p = 0.12). Intraoperative ratios were reduced to 1.4 in both groups (p = 0.6), and maintained at 1.4 during follow-up (p = 0.3). There were no infections. Two patients (9.5%) in the Augmentation group and 7 patients (25%) in the control underwent hardware removal. The median QuickDASH score was 2.3 in both groups (p=0.7), and the median NRSP score was 0.0 in the Augmentation group and 0.5 in the control (p=0.3) CONCLUSIONS: In displaced lateral clavicle fractures, plate fixation with CC ligament suture Endobutton Augmentation achieved a 100% union rate, long-term CC stability, and excellent functional results. With the numbers available in the study, the lower (92.8%) healing rate in the control group without Endobutton Augmentation did not reach statistical significance. LEVEL OF EVIDENCE: A level IV therapeutic retrospective cohort study.