Sensitivity and specificity of bell-hammer tear as an indirect sign of partial anterior cruciate ligament rupture on magnetic resonance imaging

  • N. Lefevre
  • J. F. Naouri
  • Y. Bohu
  • S. Klouche
  • S. Herman
Knee

Abstract

Purpose

The main purpose of this study was to evaluate the usefulness of the bell-hammer sign in the diagnosis of partial tears of the anterior cruciate ligament (ACL) of the knee on MRI.

Methods

A retrospective study was performed including all patients who underwent ACL reconstruction for partial or complete tears from 2008 to 2009. The diagnosis of partial or complete ACL tears was based on the appearance of the ligament bundles and the signal quality on MRI. On arthroscopy, which is considered the gold standard, each bundle was classified as normal, partially or completely torn depending on the extent of the rupture and the quality of the remaining fibres. The study included 312 patients, 83 women and 229 men (mean age 33.3 ± 19.6 years). A diagnosis of a tear was made in all patients on preoperative MRI. Arthroscopy did not show any normal ACL, 247/312 (79.2 %) complete tears and 65/312 (20.8 %) partial tears, 50/65 (76.9 %) on the anteromedial bundle (AM) and 15/65 (23.1 %) the posterolateral bundle.

Results

The bell-hammer sign was found on MRI in 13/312 patients (4.5 %). It involved 9/65 (13.8 %) partial tears, all in the AM bundle, and 4/247 (1.6 %) complete tears, significantly more frequent in cases of partial rupture (p < 0.0001). MRI diagnosed a partial tear in 15/65 cases without the bell-hammer sign (sensitivity CI95 % = 23.1 ± 10 %, specificity CI95 % = 95.9 ± 2.5 %) and with the bell-hammer sign in 23/65 cases (sensitivity CI95 % = 35.4 ± 11 %, specificity CI95 % = 93.9 ± 3 %). The association of the bell-hammer sign with conventional radiological diagnostic criteria has improved diagnosis performance of MRI for partial tears but not significantly (ns).

Conclusion

The most important interest of the bell-hammer sign in the day-to-day clinical work is to suggest partial tears on MRI. It aids making a diagnosis, but its absence does not exclude partial ACL rupture.

Level of evidence

Diagnostic study, Level II.

Keywords

ACL reconstruction Partial tear MRI diagnosis Preoperative cyclops syndrome 

References

  1. 1.
    Chun CH, Lee BC, Yang JH (2002) Extension block secondary to partial anterior cruciate ligament tear on the femoral attachment of the posterolateral bundle. Arthroscopy 18:227–231PubMedCrossRefGoogle Scholar
  2. 2.
    Cohen SB, Van Beek C, Starman JS et al (2009) MRI measurement of the 2 bundles of the normal anterior cruciate ligament. Orthopedics 32:687CrossRefGoogle Scholar
  3. 3.
    Dandy DJ, Edwards DJ (1994) Problems in regaining full extension of the knee after anterior cruciate ligament reconstruction: does arthrofibrosis exist? Knee Surg Sports Traumatol Arthrosc 2:76–79PubMedCrossRefGoogle Scholar
  4. 4.
    DeFranco MJ, Bach BR (2009) A comprehensive review of partial anterior cruciate ligament tears. J Bone Joint Surg Am 91:198–208PubMedCrossRefGoogle Scholar
  5. 5.
    Delcogliano A, Franzese S, Branca A et al (1996) Light and scan electron microscopic analysis of cyclops syndrome: etiopathogenic hypothesis and technical solutions. Knee Surg Sports Traumatol Arthrosc 4:194–199PubMedCrossRefGoogle Scholar
  6. 6.
    Duc SR, Zanetti M, Kramer J et al (2005) Magnetic resonance imaging of anterior cruciate ligament tears: evaluation of standard orthogonal and tailored paracoronal images. Acta Radiol 46:729–733PubMedCrossRefGoogle Scholar
  7. 7.
    Huang GS, Lee CH, Chan WP et al (2002) Acute anterior cruciate ligament stump entrapment in anterior cruciate ligament tears: MR imaging appearance. Radiology 225:537–540PubMedCrossRefGoogle Scholar
  8. 8.
    Irisawa H, Takahashi M, Hosokawa T, Nagano A (2007) Cyclops syndrome occurring after chronic partial rupture of the anterior cruciate ligament without surgical reconstruction. Knee Surg Sports Traumatol Arthrosc 15:144–146PubMedCrossRefGoogle Scholar
  9. 9.
    Jackson DW, Schaefer RK (1990) Cyclops syndrome: loss of extension following intra-articular anterior cruciate ligament reconstruction. Arthroscopy 6:171–178PubMedCrossRefGoogle Scholar
  10. 10.
    Lawrance JA, Ostlere SJ, Dodd CA (1996) MRI diagnosis of partial tears of the anterior cruciate ligament. Injury 27:153–155PubMedCrossRefGoogle Scholar
  11. 11.
    McMahon PJ, Dettling JR, Yocum LA, Glousman RE (1999) The cyclops lesion: a cause of diminished knee extension after rupture of the anterior cruciate ligament. Arthroscopy 15:757–761PubMedCrossRefGoogle Scholar
  12. 12.
    Monaco BR, Noble HB, Bachman DC (1982) Incomplete tears of the anterior cruciate ligament and knee locking. JAMA 19(247):1582–1584CrossRefGoogle Scholar
  13. 13.
    Nakagawa T, Hiraoka H, Fukuda A et al (2006) Symptomatic cyclops lesion after rupture of the anteromedial bundle of the anterior cruciate ligament. J Orthop Sci 11:537–540PubMedCrossRefGoogle Scholar
  14. 14.
    Palle L, Reddy B, Reddy J (2010) Sensitivity and specificity of vertically oriented lateral collateral ligament as an indirect sign of anterior cruciate ligament tear on magnetic resonance imaging. Skeletal Radiol 39:1123–1127PubMedCrossRefGoogle Scholar
  15. 15.
    Petersen W, Zantop T (2006) Partial rupture of the anterior cruciate ligament. Arthroscopy 22:1143–1145PubMedCrossRefGoogle Scholar
  16. 16.
    Runyan BR, Bancroft LW, Peterson JJ et al (2007) Cyclops lesions that occur in the absence of prior anterior ligament reconstruction. Radiographics 27:e26PubMedCrossRefGoogle Scholar
  17. 17.
    Servien E, Ait Si Salmi T, Neyret P (2003) Bell-hammer tear of anterior cruciate ligament. J Traumatol Sport 20:72–75Google Scholar
  18. 18.
    Sonnery-Cottet B, Barth J, Graveleau N et al (2009) Arthroscopic identification of isolated tear of the posterolateral bundle of the anterior cruciate ligament. Arthroscopy 25:728–732PubMedCrossRefGoogle Scholar
  19. 19.
    Steckel H, Vadala G, Davis D et al (2006) 2D and 3D 3-tesla magnetic resonance imaging of the double bundle structure in anterior cruciate ligament anatomy. Knee Surg Sports Traumatol Arthrosc 14:1151–1158PubMedCrossRefGoogle Scholar
  20. 20.
    Tonin M, Saciri V, Veselko M, Rotter A (2001) Progressive loss of knee extension after injury. Cyclops syndrome due to a lesion of the anterior cruciate ligament. Am J Sports Med 29:545–549PubMedGoogle Scholar
  21. 21.
    Van Dyck P, Vanhoenacker FM, Gielen JL et al (2011) Three tesla magnetic resonance imaging of the anterior cruciate ligament of the knee: can we differentiate complete from partial tears? Skeletal Radiol 40:701–707PubMedCrossRefGoogle Scholar
  22. 22.
    Van Dyck P, De Smet E, Veryser J et al (2012) Partial tear of the anterior cruciate ligament of the knee: injury patterns on MR imaging. Knee Surg Sports Traumatol Arthrosc 20:256–261PubMedCrossRefGoogle Scholar
  23. 23.
    Veselko M, Rotter A, Tonin M (2000) Cyclops syndrome occurring after partial rupture of the anterior cruciate ligament not treated by surgical reconstruction. Arthroscopy 16:328–331PubMedCrossRefGoogle Scholar
  24. 24.
    Walker CW, Moore TE (1997) Imaging of skeletal and soft tissue injuries in and around the knee. Radiol Clin North Am 35:631–653PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • N. Lefevre
    • 1
    • 3
  • J. F. Naouri
    • 2
  • Y. Bohu
    • 1
    • 3
  • S. Klouche
    • 1
    • 3
  • S. Herman
    • 1
    • 3
  1. 1.Orthopaedic Surgery DepartmentClinique du Sport Paris VParisFrance
  2. 2.Department of RadiologyClinique du Sport Paris VParisFrance
  3. 3.Institut de l’Appareil Locomoteur NolletParisFrance

Personalised recommendations