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The deep lateral femoral notch sign: a reliable diagnostic tool in identifying a concomitant anterior cruciate and anterolateral ligament injury

Abstract

Purpose

The aim of the present study was to investigate the validity and reliability of the deep lateral femoral notch sign (DLFNS) in identifying a concomitant anterior cruciate ligament (ACL)/anterolateral ligament (ALL) rupture and predicting the clinical outcomes following an anatomical single-bundle ACL reconstruction. It was hypothesized that patients with a concomitant ACL/ALL rupture would have an increased DLFNS compared to patients without a concomitant ACL/ALL rupture.

Methods

The lateral preoperative radiographs and MRI images of 100 patients with an ACL rupture and 100 control subjects were evaluated for the presence of a DLFNS and ACL/ALL rupture, respectively. The patients were evaluated clinically preoperatively and at a minimum 1 year following the ACL reconstruction. A receiver operator curve (ROC) analysis was performed to define the optimal cut-off value of the DLFNS for identifying a concomitant ACL/ALL injury. The relative risk (RR) was also calculated to determine whether the presence of the DLFNS was a risk factor for residual instability or ACL graft rupture following an ACL reconstruction.

Results

The prevalence of DLFNS was 52% in the ACL-ruptured patients and 15% in the control group. At a minimum 1-year follow-up, 35% (6/17) of the patients with DLFNS > 1.8 mm complained of persistent instability, and an MRI evaluation demonstrated a graft re-rupture rate of 12% (2/17). In patients with a DLFNS < 1.8 mm, 8% (7/83) reported a residual instability, and the graft rupture rate was 2.4% (2/83). A DLFNS > 1.8 mm demonstrated a sensitivity of 89%, a specificity of 95%, a negative predictive value of 98%, and a positive predictive value of 89% in identifying a concomitant ACL/ALL rupture. Patients with a DLFNS > 1.8 mm had 4.2 times increased risk for residual instability and graft rupture compared to patients with a DLFNS ≤ 1.8 mm.

Conclusions

A DLFNS > 1.8 mm could be a clinically relevant diagnostic tool for identifying a concomitant ACL/ALL rupture with high sensitivity and PPV. Patients with a DLFNS > 1.8 mm should be carefully evaluated for clinical and radiological signs of a concomitant ACL/ALL rupture and treated when needed with a combined intra-articular ACL reconstruction and extra-articular tenodesis to avoid a residual rotational instability and ACL graft rupture.

Level of evidence

III.

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References

  1. 1.

    Ardern CL, Taylor NF, Feller JA, Webster KE (2014) Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med 48:1543–1552

    Article  Google Scholar 

  2. 2.

    Cobby M, Schweitzer M, Resnick D (1992) The deep lateral femoral notch: an indirect sign of a torn anterior cruciate ligament. Radiology 184:855–858

    CAS  Article  Google Scholar 

  3. 3.

    Devitt BM, O'Sullivan R, Feller JA, Lash N, Porter TJ, Webster KE et al (2017) MRI is not reliable in diagnosing of concomitant anterolateral ligament and anterior cruciate ligament injuries of the knee. Knee Surg Sports Traumatol Arthrosc 25:1345–1351

    Article  Google Scholar 

  4. 4.

    Filardo G, Andriolo L, di Laura FG, Napoli F, Zaffagnini S, Candrian C (2019) Bone bruise in anterior cruciate ligament rupture entails a more severe joint damage affecting joint degenerative progression. Knee Surg Sports Traumatol Arthrosc 27:44–59

    Article  Google Scholar 

  5. 5.

    Filbay SR, Culvenor AG, Ackerman IN, Russell TG, Crossley KM (2015) Quality of life in anterior cruciate ligament-deficient individuals: a systematic review and meta-analysis. Br J Sports Med 49:1033–1041

    CAS  Article  Google Scholar 

  6. 6.

    Freedman KB, D'Amato MJ, Nedeff DD, Kaz A, Bach BR Jr (2003) Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med 31:2–11

    Article  Google Scholar 

  7. 7.

    Graham GP, Johnson S, Dent CM, Fairclough JA (1991) Comparison of clinical tests and the KT1000 in the diagnosis of anterior cruciate ligament rupture. Br J Sports Med 25:96–97

    CAS  Article  Google Scholar 

  8. 8.

    Grassi A, Zaffagnini S, Marcheggiani Muccioli GM, Neri MP, Della Villa S, Marcacci M (2015) After revision anterior cruciate ligament reconstruction, who returns to sport? A systematic review and meta-analysis. Br J Sports Med 49:1295–1304

    Article  Google Scholar 

  9. 9.

    Guillodo Y, Rannou N, Dubrana F, Lefevre C, Saraux A (2008) Diagnosis of anterior cruciate ligament rupture in an emergency department. J Trauma 65:1078–1082

    PubMed  Google Scholar 

  10. 10.

    Hanley JA, McNeil BJ (1982) The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 143:29–36

    CAS  Article  Google Scholar 

  11. 11.

    Kraeutler MJ, Bravman JT, McCarty EC (2013) Bone-patellar tendon-bone autograft versus allograft in outcomes of anterior cruciate ligament reconstruction: a meta-analysis of 5182 patients. Am J Sports Med 41:2439–2448

    Article  Google Scholar 

  12. 12.

    Lelli A, Di Turi RP, Spenciner DB, Dòmini M (2016) The "Lever Sign": a new clinical test for the diagnosis of anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc 24:2794–2797

    Article  Google Scholar 

  13. 13.

    Lodewijks P, Delawi D, Bollen TL, Dijkhuis GR, Wolterbeek N, Zijl JAC (2019) The lateral femoral notch sign: a reliable diagnostic measurement in acute anterior cruciate ligament injury. Knee Surg Sports Traumatol Arthrosc 27:659–664

    Article  Google Scholar 

  14. 14.

    Mall NA, Chalmers PN, Moric M, Tanaka MJ, Cole BJ, Bach BR Jr et al (2014) Incidence and trends of anterior cruciate ligament reconstruction in the United States. Am J Sports Med 42:2363–2370

    Article  Google Scholar 

  15. 15.

    Marshall T, Oak SR, Subhas N, Polster J, Winalski C, Spindler KP (2018) Can the anterolateral ligament be reliably identified in anterior cruciate ligament-intact and anterior cruciate ligament-injured knees on 3-T magnetic resonance imaging? Orthop J Sports Med 6:2325967118796452

    Article  Google Scholar 

  16. 16.

    Martinez-Camblor P, Pardo-Fernandez JC (2019) The youden index in the generalized receiver operating characteristic curve context. Int J Biostat. https://doi.org/10.1515/ijb-2018-0060

    Article  PubMed  Google Scholar 

  17. 17.

    Monaco E, Helito CP, Redler A, Argento G, De Carli A, Saithna A et al (2019) Correlation between magnetic resonance imaging and surgical exploration of the anterolateral structures of the acute anterior cruciate ligament–injured knee. Am J Sports Med 47:1186–1193

    Article  Google Scholar 

  18. 18.

    Montalvo AM, Schneider DK, Silva PL, Yut L, Webster KE, Riley MA et al (2019) 'What's my risk of sustaining an ACL injury while playing football (soccer)?' A systematic review with meta-analysis. Br J Sports Med 53:1333–1340

    Article  Google Scholar 

  19. 19.

    Muramatsu K, Saithna A, Watanabe H, Sasaki K, Yokosawa K, Hachiya Y et al (2018) Three-dimensional Magnetic Resonance Imaging of the Anterolateral Ligament of the Knee: an evaluation of intact and anterior cruciate ligament-deficient knees from the scientific anterior cruciate Ligament Network International (SANTI) Study Group. Arthroscopy 34:2207–2217

    Article  Google Scholar 

  20. 20.

    Parsons EM, Gee AO, Spiekerman C, Cavanagh PR (2015) The biomechanical function of the anterolateral ligament of the knee. Am J Sports Med 43:669–674

    Article  Google Scholar 

  21. 21.

    Patel KA, Chhabra A, Goodwin JA, Hartigan DE (2017) Identification of the Anterolateral Ligament on Magnetic Resonance Imaging. Arthrosc Tech 6:e137–e141

    Article  Google Scholar 

  22. 22.

    Patel SA, Hageman J, Quatman CE, Wordeman SC, Hewett TE (2014) Prevalence and location of bone bruises associated with anterior cruciate ligament injury and implications for mechanism of injury: a systematic review. Sports Med 44:281–293

    Article  Google Scholar 

  23. 23.

    Pavao DM, Cruz RS, de Faria JLR, de Sousa EB, Barretto JM (2019) Modified lemaire lateral tenodesis associated with an intra-articular reconstruction technique with bone-tendon-bone graft using an adjustable fixation mechanism. Arthrosc Tech 8:e733–e740

    Article  Google Scholar 

  24. 24.

    Peeler J, Leiter J, MacDonald P (2010) Accuracy and reliability of anterior cruciate ligament clinical examination in a multidisciplinary sports medicine setting. Clin J Sport Med 20:80–85

    CAS  Article  Google Scholar 

  25. 25.

    Prentice HA, Lind M, Mouton C, Persson A, Magnusson H, Gabr A et al (2018) Patient demographic and surgical characteristics in anterior cruciate ligament reconstruction: a description of registries from six countries. Br J Sports Med 52:716–722

    Article  Google Scholar 

  26. 26.

    Sharma G, Naik VA, Pankaj A (2012) Displaced osteochondral fracture of the lateral femoral condyle associated with an acute anterior cruciate ligament avulsion fracture: a corollary of "the lateral femoral notch sign". Knee Surg Sports Traumatol Arthrosc 20:1599–1602

    Article  Google Scholar 

  27. 27.

    Sonnery-Cottet B, Daggett M, Fayard JM, Ferretti A, Helito CP, Lind M et al (2017) Anterolateral Ligament Expert Group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament-deficient knee. J Orthop Traumatol 18:91–106

    Article  Google Scholar 

  28. 28.

    Terzidis IP, Christodoulou AG, Ploumis AL, Metsovitis SR, Koimtzis M, Givissis P (2004) The appearance of kissing contusion in the acutely injured knee in the athletes. Br J Sports Med 38:592–596

    CAS  Article  Google Scholar 

  29. 29.

    Waiwaiole A, Gurbani A, Motamedi K, Seeger L, Sim MS, Nwajuaku P et al (2016) Relationship of ACL injury and posterior tibial slope with patient age, sex, and race. Orthop J Sports Med 4:2325967116672852

    Article  Google Scholar 

  30. 30.

    Waiwaiole A, Gurbani A, Motamedi K, Seeger L, Sim MS, Nwajuaku P et al (2016) Relationship of ACL injury and posterior tibial slope with patient age, sex, and race. Orthopaed J Sports Med 4:2325967116672852

    Article  Google Scholar 

  31. 31.

    Waldén M, Hägglund M, Magnusson H, Ekstrand J (2016) ACL injuries in men's professional football: a 15-year prospective study on time trends and return-to-play rates reveals only 65% of players still play at the top level 3 years after ACL rupture. Br J Sports Med 50:744–750

    Article  Google Scholar 

Download references

Funding

This research was funded by the National Natural Science Foundation of China Grant numbers [31771017 and 31972924], the Science and Technology Commission of Shanghai Municipality, Grant number [16441908700], the Innovation Research Plan supported by Shanghai Municipal Education Commission, Grant number [ZXWF082101], Key Technologies Research and Development Program, Grant numbers [2017YFC0110700, 2019YFC010262, and 2019YFC0120601], and the Interdisciplinary Program of Shanghai Jiao Tong University, Grant numbers [ZH2018QNA06, YG2017MS09].

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Correspondence to Tsung-Yuan Tsai.

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The authors of this manuscript have nothing to disclose that would bias our work.

Ethical approval

The present single-center, retrospective study was approved by the authors’ institutional Internal Review Board and the ethical committee (Ethical Committee Northeast and Central Switzerland 2018-01410).

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Ethikkommission Nordwest-und Zentralschweiz: 2018-01410.

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Dimitriou, D., Reimond, M., Foesel, A. et al. The deep lateral femoral notch sign: a reliable diagnostic tool in identifying a concomitant anterior cruciate and anterolateral ligament injury. Knee Surg Sports Traumatol Arthrosc 29, 1968–1976 (2021). https://doi.org/10.1007/s00167-020-06278-w

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Keywords

  • Anterior cruciate ligament
  • Anterolateral ligament
  • Deep lateral femoral notch sign
  • Radiograph
  • Clinical outcomes