{'fraction_non_alphanumeric': 0.020530367835757058, 'fraction_numerical': 0.004562303963501569, 'mean_word_length': 5.230905861456483, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Is Treatment of Segond Fracture Necessary With Combined Anterior Cruciate Ligament Reconstruction? Letter to the Editor

Dear Editor: We read with great interest the recent study by Melugin et al titled ‘‘Is Treatment of Segond Fracture Necessary With Combined Anterior Cruciate Ligament Reconstruction?’’ The authors conclude that patients with a combined anterior cruciate ligament (ACL) rupture and untreated Segond fracture have outcomes comparable to those of an isolated ACL rupture when treated with ACL reconstruction alone. Unfortunately, this conclusion seems unreasonable from this study. The authors mentioned that the Segond fracture was at the site of the anterolateral ligament (ALL) and that the ALL alone was a major contributor to rotational stability of the knee at different flexion angles. Then, for the purpose of the study, the authors matched a group of patients with Segond fracture and a group without associated Segond fracture by sex, age, graft type, and body mass index. However, ligament injury could be presented either as an avulsion fracture or as an occult rupture of any site within a ligament. Ferretti et al found that while Segond fractures appeared in about 10% of cases, a kind of soft tissue, intraligamentous injury of the ALC and concomitant anterolateral capsule damage were found in up to 90% of cases, and these structures appear to affect the pivot-shift phenomenon. Thus, it is reasonable to assume that some patients with ALL injury, not an avulsion fracture but a ligamentous tissue injury, were included in the control group. Statistical significance of the preoperative pivot-shift test between the two groups may be the result of Segond fracture to some extent. However, the Segond group had significantly more anteroposterior instability by preoperative Lachman testing. Therefore, it is possible that some other factors contributed to this difference instead of Segond fractures between two groups. In a mean 59.1 months (range, 24-180 months) of followup, the Segond group had the same results regarding anteroposterior and rotational stability as the control group. The authors also mentioned that time to fracture healing was 4 months (range, 3-30 months) after injury. It seems that the authors lost the most important information. Was the functional recovery obtained accordingly with the time of bone healing? The function of the rotational limit of the ALL would not be obtained before bone healing. Considering this, we could simplify the question addressed by this study as ‘‘is untreated Segond fracture finally healed?’’ Surgeons do try to fix the Segond fracture and hope to provide better knee function. Moreover, some research demonstrates that Segond fracture is not an avulsion of single structure but rather varies. So deciding whether a Segond fracture should be treated should not be based on the functional outcome. Above all, given the confusing stratification of patients and inappropriate outcome measurement, we could only conclude that when their bones healed, patients with a combined ACL rupture and untreated Segond fracture had outcomes comparable to those of selected patients with isolated ACL rupture when treated with ACL reconstruction alone. We need further prospective studies to determine how to treat a Segond fracture, surgically or conservatively. The primary focus of such studies should be bone healing and at what level Segond fracture affects rotational stability and rehabilitation progress before healing.