Skip to main content
SpringerLink
Log in

The tibial tubercle–posterior cruciate ligament (TT–PCL) distance does not truly reflect the lateralization of the tibial tubercle

  • KNEE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The role of the tibial tubercle–posterior cruciate ligament (TT–PCL) and tibial tubercle–trochlear groove (TT–TG) in recurrent patellar instability (RPI) remains unclear. This study aims to confirm the validity of the TT–TG and TT–PCL in predicting RPI and to verify whether the TT–PCL can truly reflect the lateralization of the tibial tubercle.

Methods

A total of 50 patients with RPI and 50 controls were recruited and underwent magnetic resonance imaging examinations. The TT–TG, TT–PCL, and tibial tubercle lateralization (TTL) were measured independently by two authors in a blinded and randomized fashion. T-test was used for parametric variances and the Mann–Whitney U and Chi-square tests were used for non-parametric variances. Pearson’s product moment correlation coefficients were calculated to determine correlations between the defined measurements. The intraclass correlation coefficient was used to assess the reliability of the measurements.

Results

All defined measurements showed excellent intra- and inter-observer reliability. The TT–TG distance, TT–PCL distance, and TTL were significantly greater in the PI group than in the control group. The AUC was highest for the TT–TG distance compared with that for the TT–PCL distance, and TTL were 0.798, 0.764, and 0.769, with the calculated cut-off value of 12.5 mm, 16.5 mm, and 66.1 percentages. There was a moderate correlation (r = 0.595) between the TT–TG distance and TTL, and a weak correlation (r = 0.430) between the TT–PCL distance and TTL.

Conclusion

Both the TT–TG distance and TT–PCL distance can be measured with excellent reliability on magnetic resonance imaging. The TT–TG distance, rather than the TT–PCL distance, has a better performance in predicting RPI. Most interestingly, the TT–PCL distance cannot reflect the real lateralization of TT. This study provides new information to evaluate TTL in patients with RPI.

Level of evidence

III.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

Availability of data and materials

We would like to open our data and material if needed.

Code availability

KSST-D-21-00625.

References

  1. Ackermann J, Hasler J, Graf DN, Fucentese SF, Vlachopoulos L (2021) The effect of native knee rotation on the tibial-tubercle-trochlear-groove distance in patients with patellar instability: an analysis of MRI and CT measurements. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-021-03947-4

  2. Anley CM, Morris GV, Saithna A, James SL, Snow M (2015) Defining the role of the tibial tubercle-trochlear groove and tibial tubercle-posterior cruciate ligament distances in the work-up of patients with patellofemoral disorders. Am J Sports Med 43:1348–1353

    Article  Google Scholar 

  3. Boutris N, Delgado DA, Labis JS, McCulloch PC, Lintner DM, Harris JD (2018) Current evidence advocates use of a new pathologic tibial tubercle-posterior cruciate ligament distance threshold in patients with patellar instability. Knee Surg Sports Traumatol Arthrosc 26:2733–2742

    Article  Google Scholar 

  4. Camp CL, Stuart MJ, Krych AJ, Levy BA, Bond JR, Collins MS et al (2013) CT and MRI measurements of tibial tubercle-trochlear groove distances are not equivalent in patients with patellar instability. Am J Sports Med 41:1835–1840

    Article  Google Scholar 

  5. Clifton B, Richter DL, Tandberg D, Ferguson M, Treme G (2017) Evaluation of the tibial tubercle to posterior cruciate ligament distance in a pediatric patient population. J Pediatr Orthop 37:e388–e393

    Article  Google Scholar 

  6. Dejour H, Walch G, Nove-Josserand L, Guier C (1994) Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc 2:19–26

    Article  CAS  Google Scholar 

  7. Dickens AJ, Morrell NT, Doering A, Tandberg D, Treme G (2014) Tibial tubercle-trochlear groove distance: defining normal in a pediatric population. J Bone Jt Surg Am 96:318–324

    Article  Google Scholar 

  8. Dornacher D, Reichel H, Lippacher S (2014) Measurement of tibial tuberosity-trochlear groove distance: evaluation of inter- and intraobserver correlation dependent on the severity of trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc 22:2382–2387

    Article  Google Scholar 

  9. Friedman MV, Hillen TJ, Misra S, Hildebolt CF, Rubin DA (2020) Quantitative variable assessment of patellar instability: an MRI-based study. Am J Roentgenol 215:1163–1170

    Article  Google Scholar 

  10. Goutallier D, Bernageau J, Lecudonnec B (1978) The measurement of the tibial tuberosity. Patella groove distanced technique and results (author’s transl). Rev Chir Orthop Reparatrice Appar Mot 64:423–428

    CAS  PubMed  Google Scholar 

  11. Hayat Z, El Bitar Y, Case JL (2021) Patella Dislocation. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2021, StatPearls Publishing LLC

  12. Heidenreich MJ, Camp CL, Dahm DL, Stuart MJ, Levy BA, Krych AJ (2017) The contribution of the tibial tubercle to patellar instability: analysis of tibial tubercle-trochlear groove (TT-TG) and tibial tubercle-posterior cruciate ligament (TT-PCL) distances. Knee Surg Sports Traumatol Arthrosc 25:2347–2351

    Article  Google Scholar 

  13. Heidenreich MJ, Sanders TL, Hevesi M, Johnson NR, Wu IT, Camp CL et al (2018) Individualizing the tibial tubercle to trochlear groove distance to patient specific anatomy improves sensitivity for recurrent instability. Knee Surg Sports Traumatol Arthrosc 26:2858–2864

    Article  Google Scholar 

  14. Hernigou J, Chahidi E, Bouaboula M, Moest E, Callewier A, Kyriakydis T et al (2018) Knee size chart nomogram for evaluation of tibial tuberosity-trochlear groove distance in knees with or without history of patellofemoral instability. Int Orthop 42:2797–2806

    Article  Google Scholar 

  15. Hinton RY, Sharma KM (2003) Acute and recurrent patellar instability in the young athlete. Orthop Clin North Am 34:385–396

    Article  Google Scholar 

  16. Howell SM, Chen J, Hull ML (2013) Variability of the location of the tibial tubercle affects the rotational alignment of the tibial component in kinematically aligned total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 21:2288–2295

    Article  Google Scholar 

  17. Ikuta Y, Ishikawa M, Suga N, Nakamae A, Nakasa T, Adachi N (2020) New standardization method of tibial tubercle-posterior cruciate ligament distance according to patient size in patients with patellofemoral instability. Knee 27:695–700

    Article  Google Scholar 

  18. Kuroda R, Kambic H, Valdevit A, Andrish JT (2001) Articular cartilage contact pressure after tibial tuberosity transfer. A cadaveric study. Am J Sports Med 29:403–409

    Article  CAS  Google Scholar 

  19. Lin KM, James EW, Aitchison AH, Schlichte LM, Wang G, Green DW (2021) Increased tibiofemoral rotation on MRI with increasing clinical severity of patellar instability. Knee Surg Sports Traumatol Arthrosc 29:3735–3742

    Article  Google Scholar 

  20. Marquez-Lara A, Andersen J, Lenchik L, Ferguson CM, Gupta P (2017) Variability in patellofemoral alignment measurements on mri: influence of knee position. Am J Roentgenol 208:1097–1102

    Article  Google Scholar 

  21. McFarlane KH, Coene RP, Feldman L, Miller PE, Heyworth BE, Kramer DE et al (2021) Increased incidence of acute patellar dislocations and patellar instability surgical procedures across the United States in paediatric and adolescent patients. J Child Orthop 15:149–156

    Article  Google Scholar 

  22. Mistovich RJ, Urwin JW, Fabricant PD, Lawrence JTR (2018) Patellar tendon-lateral trochlear ridge distance: a novel measurement of patellofemoral instability. Am J Sports Med 46:3400–3406

    Article  Google Scholar 

  23. Moya-Angeler J, Vairo GL, Bader DA, Sebastianelli WJ, Sherbondy PS (2021) The TT-TG distance/trochlear dysplasia index quotient is the most accurate indicator for determining patellofemoral instability risk. Arthroscopy. https://doi.org/10.1016/j.arthro.2021.08.018

    Article  PubMed  Google Scholar 

  24. Paiva M, Blønd L, Hölmich P, Barfod KW (2021) Effect of medialization of the trochlear groove and lateralization of the tibial tubercle on TT-TG distance: a cross-sectional study of dysplastic and nondysplastic knees. Am J Sports Med 49:970–974

    Article  Google Scholar 

  25. Prakash J, Seon JK, Ahn HW, Cho KJ, Im CJ, Song EK (2018) Factors affecting tibial tuberosity-trochlear groove distance in recurrent patellar dislocation. Clin Orthop Surg 10:420–426

    Article  Google Scholar 

  26. Salvatore G, Berton A, Orsi A, Egan J, Walley KC, Johns WL et al (2021) Lateral release with tibial tuberosity transfer alters patellofemoral biomechanics promoting multidirectional patellar instability. Arthroscopy. https://doi.org/10.1016/j.arthro.2021.08.008

    Article  PubMed  Google Scholar 

  27. Schoettle PB, Zanetti M, Seifert B, Pfirrmann CW, Fucentese SF, Romero J (2006) The tibial tuberosity-trochlear groove distance; a comparative study between CT and MRI scanning. Knee 13:26–31

    Article  Google Scholar 

  28. Seitlinger G, Scheurecker G, Högler R, Labey L, Innocenti B, Hofmann S (2012) Tibial tubercle-posterior cruciate ligament distance: a new measurement to define the position of the tibial tubercle in patients with patellar dislocation. Am J Sports Med 40:1119–1125

    Article  Google Scholar 

  29. Song YF, Wang HJ, Yan X, Yuan FZ, Xu BB, Chen YR et al (2021) Tibial tubercle osteotomy may not provide additional benefit in treating patellar dislocation with increased tibial tuberosity-trochlear groove distance: a systematic review. Arthroscopy 37:1670-1679.e1671

    Article  Google Scholar 

  30. Stephen JM, Lumpaopong P, Dodds AL, Williams A, Amis AA (2015) The effect of tibial tuberosity medialization and lateralization on patellofemoral joint kinematics, contact mechanics, and stability. Am J Sports Med 43:186–194

    Article  Google Scholar 

  31. Sundararajan SR, Raj M, Ramakanth R, Muhil K, Rajasekaran S (2020) Prediction of recurrence based on the patellofemoral morphological profile and demographic factors in first-time and recurrent dislocators. Int Orthop 44:2305–2314

    Article  Google Scholar 

  32. Tensho K, Akaoka Y, Shimodaira H, Takanashi S, Ikegami S, Kato H et al (2015) What components comprise the measurement of the tibial tuberosity-trochlear groove distance in a patellar dislocation population? J Bone Jt Surg Am 97:1441–1448

    Article  Google Scholar 

  33. Tensho K, Shimodaira H, Akaoka Y, Koyama S, Hatanaka D, Ikegami S et al (2018) Lateralization of the tibial tubercle in recurrent patellar dislocation: verification using multiple methods to evaluate the tibial tubercle. J Bone Jt Surg Am 100:e58

    Article  Google Scholar 

  34. Tscholl PM, Antoniadis A, Dietrich TJ, Koch PP, Fucentese SF (2016) The tibial-tubercle trochlear groove distance in patients with trochlear dysplasia: the influence of the proximally flat trochlea. Knee Surg Sports Traumatol Arthrosc 24:2741–2747

    Article  Google Scholar 

  35. Uimonen MM, Repo JP, Huttunen TT, Nurmi H, Mattila VM, Paloneva J (2021) Surgery for patellar dislocation has evolved towards anatomical reconstructions with assessment and treatment of anatomical risk factors. Knee Surg Sports Traumatol Arthrosc 29:1944–1951

    Article  Google Scholar 

  36. Vairo GL, Moya-Angeler J, Siorta MA, Anderson AH, Sherbondy PS (2019) Tibial Tubercle-Trochlear groove distance is a reliable and accurate indicator of patellofemoral instability. Clin Orthop Relat Res 477:1450–1458

    Article  Google Scholar 

  37. Xu Z, Zhang H, Fu B, Mohamed SI, Zhang J, Zhou A (2020) Tibial tubercle-roman arch distance: a new measurement of patellar dislocation and indication of tibial tubercle osteotomy. Orthop J Sports Med 8:2325967120914872

    PubMed  PubMed Central  Google Scholar 

  38. Xu Z, Zhang H, Yan W, Qiu M, Zhang J, Zhou A (2021) Validating the role of tibial tubercle-posterior cruciate ligament distance and tibial tubercle-trochlear groove distance measured by magnetic resonance imaging in patients with patellar dislocation: a diagnostic study. Arthroscopy 37:234–242

    Article  CAS  Google Scholar 

Download references

Acknowledgements

We declare that we have no financial and personal relationships with other people or organizations that can inappropriately influence our work, there is no professional or other personal interest of any nature or kind in any product, service and/or company that could be construed as influencing the position presented in, or the review of, the manuscript entitled.

Funding

There is no funding to support this study.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China

    Zhenyue Dong, Chenyue Xu, Gang Ji, Yingzhen Niu & Fei Wang

  2. Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China

    Xiaoxiao Zhang

Authors
  1. Zhenyue Dong
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Xiaoxiao Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Chenyue Xu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gang Ji
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yingzhen Niu
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Fei Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Fei Wang.

Ethics declarations

Conflict of interest

No conflict of interest exits in the submission of this manuscript, and manuscript is approved by all authors for publication.

Ethical approval

All procedures performed were in accordance with the ethical standards of the institutional review board and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Human and animal rights

This article does not contain any studies with animals performed by any of the authors.

Informed consent

For this type of study, formal consent is not required.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (XLSX 14 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dong, Z., Zhang, X., Xu, C. et al. The tibial tubercle–posterior cruciate ligament (TT–PCL) distance does not truly reflect the lateralization of the tibial tubercle. Knee Surg Sports Traumatol Arthrosc 30, 3470–3479 (2022). https://doi.org/10.1007/s00167-022-06927-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-022-06927-2

Keywords

Search

Navigation