Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 23, Issue 8, pp 2178–2184 | Cite as

Varus knee osteoarthritis: how can we identify ACL insufficiency?

  • Wenzel Waldstein
  • Christian Merle
  • Jad Bou Monsef
  • Friedrich BoettnerEmail author



The aim of this prospective study was to determine the clinical value of lateral radiographs and corresponding MRI scans in the preoperative evaluation of the functional integrity of the anterior cruciate ligament (ACL) in a consecutive series of 78 patients (93 knees) with medial compartment osteoarthritis.


All knees received standardised radiographs and MRI imagery. The wear pattern on the lateral radiograph was described based on a modified Keyes classification. On MRI, the ACL and the percentage of intact posterior cartilage in relation to the anteroposterior tibia width were assessed.


The MRI showed an intact ACL in 23 (25 %) knees, evidence of ACL degeneration in 54 (58 %) knees and a complete ACL tear in 16 (17 %) knees. All knees with an intact ACL showed ≥14 % intact posterior cartilage on sagittal MRI scans, except for one knee. All knees with a torn ACL demonstrated <14 % intact posterior cartilage. Of the 54 knees with evidence of ACL degeneration, eight knees had <14 % intact posterior cartilage similar to the wear pattern present in knees with torn ACLs. Out of the 24 knees with a torn or degenerated ACL and <14 % intact posterior cartilage on MRI, 23 (96 %) knees demonstrated posterior bony erosion on corresponding lateral radiographs.


The assessment of intact posterior tibial cartilage on MRI and lateral radiographs helps to identify knees with functional ACL insufficiency. MRI with assessment of both the ACL morphology and the underlying tibial wear pattern appears to provide additional clinical benefit in cases in which the extent of posterior bony erosion on the lateral radiograph cannot be assessed with confidence.

Level of evidence

Diagnostic study, Level II.


ACL Function Insufficiency Degeneration Cartilage wear pattern MRI Lateral radiographs 



The institution of the authors has received funding from Smith and Nephew Inc (Memphis, TN, USA).

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Fergusson CM (2000) Management of the young patient with an osteoarthritic knee. In: Allum RL, Fergusson CM, Thomas NP (eds) Clinical challenges in orthopaedics: the knee. Martin Dunitz Ltd, LondonGoogle Scholar
  2. 2.
    Goodfellow J, O’Connor J (1992) The anterior cruciate ligament in knee arthroplasty. A risk-factor with unconstrained meniscal prostheses. Clin Orthop Relat Res 276:245–252PubMedGoogle Scholar
  3. 3.
    Goodfellow JW, O’Connor J, Dodd CA, Murray DW (2006) Unicompartmental arthroplasty with the Oxford Knee. Oxford University Press, OxfordGoogle Scholar
  4. 4.
    Hovis KK, Alizai H, Tham SC, Souza RB, Nevitt MC, McCulloch CE, Link TM (2012) Non-traumatic anterior cruciate ligament abnormalities and their relationship to osteoarthritis using morphological grading and cartilage T2 relaxation times: data from the osteoarthritis initiative (OAI). Skelet Radiol 41(11):1435–1443CrossRefGoogle Scholar
  5. 5.
    Johnson AJ, Howell SM, Costa CR, Mont MA (2013) The ACL in the arthritic knee: how often is it present and can preoperative tests predict its presence? Clin Orthop Relat Res 471(1):181–188PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16(4):494–502PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Kendrick BJ, Rout R, Bottomley NJ, Pandit H, Gill HS, Price AJ, Dodd CA, Murray DW (2010) The implications of damage to the lateral femoral condyle on medial unicompartmental knee replacement. J Bone Joint Surg Br 92(3):374–379PubMedCrossRefGoogle Scholar
  8. 8.
    Keyes GW, Carr AJ, Miller RK, Goodfellow JW (1992) The radiographic classification of medial gonarthrosis. correlation with operation methods in 200 knees. Acta Orthop Scand 63(5):497–501PubMedCrossRefGoogle Scholar
  9. 9.
    Kozinn SC, Scott R (1989) Unicondylar knee arthroplasty. J Bone Joint Surg Am 71(1):145–150PubMedGoogle Scholar
  10. 10.
    Marx RG, Grimm P, Lillemoe KA, Robertson CM, Ayeni OR, Lyman S, Bogner EA, Pavlov H (2011) Reliability of lower extremity alignment measurement using radiographs and PACS. Knee Surg Sports Traumatol Arthrosc 19(10):1693–1698PubMedCrossRefGoogle Scholar
  11. 11.
    Merle C, Waldstein W, Pegg E, Streit MR, Gotterbarm T, Aldinger PR, Murray DW, Gill HS (2012) Femoral offset is underestimated on anteroposterior radiographs of the pelvis but accurately assessed on anteroposterior radiographs of the hip. J Bone Joint Surg Br 94(4):477–482PubMedCrossRefGoogle Scholar
  12. 12.
    Moreland JR, Bassett LW, Hanker GJ (1987) Radiographic analysis of the axial alignment of the lower extremity. J Bone Joint Surg Am 69(5):745–749PubMedGoogle Scholar
  13. 13.
    Mullaji AB, Marawar SV, Luthra M (2008) Tibial articular cartilage wear in varus osteoarthritic knees: correlation with anterior cruciate ligament integrity and severity of deformity. J Arthroplast 23(1):128–135CrossRefGoogle Scholar
  14. 14.
    Pandit H, Beard DJ, Jenkins C, Kimstra Y, Thomas NP, Dodd CA, Murray DW (2006) Combined anterior cruciate reconstruction and Oxford unicompartmental knee arthroplasty. J Bone Joint Surg Br 88(7):887–892PubMedCrossRefGoogle Scholar
  15. 15.
    Pandit H, Gulati A, Jenkins C, Barker K, Price AJ, Dodd CA, Murray DW (2011) Unicompartmental knee replacement for patients with partial thickness cartilage loss in the affected compartment. Knee 18(3):168–171PubMedCrossRefGoogle Scholar
  16. 16.
    Ries MD (2007) Effect of ACL sacrifice, retention, or substitution on kinematics after TKA. Orthopedics 30(8 Suppl):74–76PubMedGoogle Scholar
  17. 17.
    Rout R, McDonnell S, Hulley P, Jayadev C, Khan T, Carr A, Murray D, Gill H, Price A (2013) The pattern of cartilage damage in antero-medial osteoarthritis of the knee and its relationship to the anterior cruciate ligament. J Orthop Res 31(6):908–913PubMedCrossRefGoogle Scholar
  18. 18.
    Schindler OS, Scott WN, Scuderi GR (2010) The practice of unicompartmental knee arthroplasty in the United Kingdom. J Orthop Surg 18(3):312–319Google Scholar
  19. 19.
    Sharpe I, Tyrrell PN, White SH (2001) Magnetic resonance imaging assessment for unicompartmental knee replacement: a limited role. Knee 8(3):213–218PubMedCrossRefGoogle Scholar
  20. 20.
    Van Dyck P, De Smet E, Veryser J, Lambrecht V, Gielen JL, Vanhoenacker FM, Dossche L, Parizel PM (2012) Partial tear of the anterior cruciate ligament of the knee: injury patterns on MR imaging. Knee Surg Sports Traumatol Arthrosc 20(2):256–261PubMedCrossRefGoogle Scholar
  21. 21.
    Waldstein W, Monsef JB, Buckup J, Boettner F (2013) The value of valgus stress radiographs in the workup for medial unicompartmental arthritis. Clin Orthop Relat Res 471(12):3998–4003PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    White SH, Ludkowski PF, Goodfellow JW (1991) Anteromedial osteoarthritis of the knee. J Bone Joint Surg Br 73(4):582–586PubMedGoogle Scholar
  23. 23.
    Willis-Owen CA, Brust K, Alsop H, Miraldo M, Cobb JP (2009) Unicondylar knee arthroplasty in the UK National Health Service: an analysis of candidacy, outcome and cost efficacy. Knee 16(6):473–478PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Wenzel Waldstein
    • 1
  • Christian Merle
    • 2
  • Jad Bou Monsef
    • 1
  • Friedrich Boettner
    • 1
    Email author
  1. 1.Adult Reconstruction and Joint Replacement DivisionHospital for Special SurgeryNew YorkUSA
  2. 2.Department of Orthopaedic and Trauma SurgeryUniversity Hospital HeidelbergHeidelbergGermany

Personalised recommendations