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



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.


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.


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.


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.

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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).

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