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The posterior cruciate ligament–posterior femoral cortex angle (PCL–PCA) and the lateral collateral ligament (LCL) sign are useful parameters to indicate the progression of knee decompensation over time after an ACL injury

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The posterior cruciate ligament–posterior cortex angle (angle between the most vertical part of the anterolateral PCL bundle and the posterior diaphyseal cortex of the femur; PCL–PCA) is the most accurate approach to describe the PCL buckling phenomenon observed in anterior cruciate ligament (ACL)-deficient knees. The aim of this study was to determine whether the PCL–PCA is associated with chronicity of the ACL rupture, the meniscal status, preoperative knee laxity or imaging signs such as the lateral collateral ligament (LCL) sign or the posterior tibial slope (PTS) in ACL-injured knees.

Methods

Patients with a primary ACL reconstruction (ACLR) after physeal closure were selected retrospectively from a hospital-based ACL registry from 2015 to 2021. Exclusion criteria were: previous ipsilateral/contralateral knee surgery, previous ipsilateral ACL or meniscal tear, ipsilateral PCL and/or collateral ligament injuries or tibial plateau fracture. The ACL deficiency was defined as chronic if time from injury to MRI was > 6 months. The meniscal status was assessed during ACLR, separately for the medial and lateral meniscus, and classified into no tear, minor or major unstable tear. The MRI analyses included the assessment of the PCL–PCA and the LCL sign. PTS was assessed from the lateral plain radiographs of the injured knee. The side-to-side difference in anterior tibial translation (ATT) at 200N was obtained with the GNRB.

Results

Eighty-two patients (forty-eight males/thirty-four females) were included in this study. The median PCL–PCA was 16.2° (Q1–Q3: 10.6–24.7) and differed between acute (18.4°) and chronic (10.7°) injuries (p < 0.01). The median PCL–PCA was significantly lower (− 4.6°) in patients with a positive LCL sign (p = 0.03) No significant association could be found between PCL–PCA and meniscal status, PTS or preoperative anterior knee laxity (Lachman, pivot shift and ATT in millimetres).

Conclusion

The PCL–PCA was significantly lower in chronic ACL injuries and in patients with a positive LCL sign, indicating a higher buckling phenomenon of the PCL in these patients. These results support the fact that PCL–PCA and the LCL sign may be useful parameters to indicate the progression of knee decompensation over time after an ACL injury, and therefore may constitute a helpful tool to optimise treatment choice and timing of ACL reconstruction if necessary.

Level of evidence

III.

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Data availability

Not applicable.

Abbreviations

ACL:

Anterior cruciate ligament

LCL:

Lateral collateral ligament

PCL:

Posterior cruciate ligament

MRI:

Magnetic resonance imaging

ATT:

Anterior tibial translation

PCL–PCA:

Posterior cruciate ligament–posterior cortex angle

PTS:

Posterior tibial slope

ACLR:

ACL reconstruction

TFI:

Time from injury

ACLISS:

Anterior Cruciate Ligament Injury Severity Scale

References

  1. Boeree NR, Ackroyd CE (1992) Magnetic resonance imaging of anterior cruciate ligament rupture. A new diagnostic sign. J Bone Joint Surg Br 74:614–616

    Article  CAS  PubMed  Google Scholar 

  2. Chang MJ, Chang CB, Choi JY, Je MS, Kim TK (2014) Can magnetic resonance imaging findings predict the degree of knee joint laxity in patients undergoing anterior cruciate ligament reconstruction? BMC Musculoskelet Disord 15:214. https://doi.org/10.1186/1471-2474-15-214

    Article  PubMed  PubMed Central  Google Scholar 

  3. Coffey R, Bordoni B (2022) Lachman Test. StatPearls

  4. DeFrate LE, Gill TJ, Li G (2004) In vivo function of the posterior cruciate ligament during weightbearing knee flexion. Am J Sports Med 32:1923–1928

    Article  PubMed  Google Scholar 

  5. Dejour D, Pungitore M, Valluy J, Nover L, Saffarini M, Demey G (2019) Preoperative laxity in ACL-deficient knees increases with posterior tibial slope and medial meniscal tears. Knee Surg Sports Traumatol Arthrosc 27:564–572

    Article  PubMed  Google Scholar 

  6. Evans J, Nielson J (2022) Anterior cruciate ligament knee injuries. StatPearls

  7. Grassi A, Di Paolo S, Lucidi GA, Macchiarola L, Raggi F, Zaffagnini S (2019) The contribution of partial meniscectomy to preoperative laxity and laxity after anatomic single-bundle anterior cruciate ligament reconstruction. In vivo kinematics with navigation. Am J Sports Med 47:3203–3211

    Article  PubMed  Google Scholar 

  8. Hong CK, Hoshino Y, Watanabe S, Nagai K, Matsushita T, Su WR et al (2022) The coronal lateral collateral ligament sign in the anterior cruciate ligament-injured knees was observed regardless of the knee laxity based on the quantitative measurements. Knee Surg Sports Traumatol Arthrosc 30:3508–3514

    Article  PubMed  Google Scholar 

  9. Huang TC, Liu ZW, Hong CK, Wang CH, Hsu KL, Kuan FC et al (2022) The lateral femoral notch sign and coronal lateral collateral ligament sign in magnetic resonance imaging failed to predict dynamic anterior tibial laxity. BMC Musculoskelet Disord 23:402. https://doi.org/10.1186/s12891-022-05368-9

    Article  PubMed  PubMed Central  Google Scholar 

  10. Jahn R, Cooper JD, Juhan T, Kang HP, Bolia IK, Gamradt SC et al (2021) Reliability of plain radiographs versus magnetic resonance imaging to measure tibial slope in sports medicine patients: can they be used interchangeably? Orthop J Sports Med 9:23259671211033880

    PubMed  PubMed Central  Google Scholar 

  11. LaPrade RF, Oro FB, Ziegler CG, Wijdicks CA, Walsh MP (2010) Patellar height and tibial slope after opening-wedge proximal tibial osteotomy: a prospective study. Am J Sports Med 38:160–170

    Article  PubMed  Google Scholar 

  12. Macchiarola L, Jacquet C, Dor J, Zaffagnini S, Mouton C, Seil R (2022) Side-to-side anterior tibial translation on monopodal weightbearing radiographs as a sign of knee decompensation in ACL-deficient knees. Knee Surg Sports Traumatol Arthrosc 30:1691–1699

    Article  PubMed  Google Scholar 

  13. Magosch A, Jacquet C, Nuhrenborger C, Mouton C, Seil R (2022) Grade III pivot shift as an early sign of knee decompensation in chronic ACL-injured knees with bimeniscal tears. Knee Surg Sports Traumatol Arthrosc 30:1611–1619

    Article  PubMed  Google Scholar 

  14. Mink JH, Levy T, Crues JV 3rd (1988) Tears of the anterior cruciate ligament and menisci of the knee: MR imaging evaluation. Radiology 167:769–774

    Article  CAS  PubMed  Google Scholar 

  15. Mishima S, Takahashi S, Kondo S, Ishiguro N (2005) Anterior tibial subluxation in anterior cruciate ligament-deficient knees: quantification using magnetic resonance imaging. Arthroscopy 21:1193–1196

    Article  PubMed  Google Scholar 

  16. Mitchell BC, Siow MY, Bastrom T, Bomar JD, Pennock AT, Parvaresh K et al (2021) Coronal lateral collateral ligament sign: a novel magnetic resonance imaging sign for identifying anterior cruciate ligament-deficient knees in adolescents and summarizing the extent of anterior tibial translation and femorotibial internal rotation. Am J Sports Med 49:928–934

    Article  PubMed  Google Scholar 

  17. Mouton C, Seil R, Meyer T, Agostinis H, Theisen D (2015) Combined anterior and rotational laxity measurements allow characterizing personal knee laxity profiles in healthy individuals. Knee Surg Sports Traumatol Arthrosc 23:3571–3577

    Article  PubMed  Google Scholar 

  18. Musahl V, Citak M, O’Loughlin PF, Choi D, Bedi A, Pearle AD (2010) The effect of medial versus lateral meniscectomy on the stability of the anterior cruciate ligament-deficient knee. Am J Sports Med 38:1591–1597

    Article  PubMed  Google Scholar 

  19. Nadeem B, Bacha R, Gilani SA (2018) Correlation of subcutaneous fat measured on ultrasound with body mass index. J Med Ultrasound 26:205–209

    Article  PubMed  PubMed Central  Google Scholar 

  20. Papannagari R, DeFrate LE, Nha KW, Moses JM, Moussa M, Gill TJ et al (2007) Function of posterior cruciate ligament bundles during in vivo knee flexion. Am J Sports Med 35:1507–1512

    Article  PubMed  Google Scholar 

  21. Sawilowsky S (2009) New effect size rules of thumb. J Mod Appl Stat Methods 8:597–599

    Article  Google Scholar 

  22. Schweitzer ME, Cervilla V, Kursunoglu-Brahme S, Resnick D (1992) The PCL line: an indirect sign of anterior cruciate ligament injury. Clin Imaging 16:43–48

    Article  CAS  PubMed  Google Scholar 

  23. Seil R, Pioger C, Siboni R, Amendola A, Mouton C (2023) The anterior cruciate ligament injury severity scale (ACLISS) is an effective tool to document and categorize the magnitude of associated tissue damage in knees after primary ACL injury and reconstruction. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-023-07311-4

    Article  PubMed  Google Scholar 

  24. Shu L, Abe N, Li S, Sugita N (2022) Importance of posterior tibial slope in joint kinematics with an anterior cruciate ligament-deficient knee. Bone Joint Res 11:739–750

    Article  PubMed  PubMed Central  Google Scholar 

  25. Siboni R, Pioger C, Mouton C, Seil R (2022) The posterior cruciate ligament-posterior femoral cortex angle: a reliable and accurate MRI method to quantify the buckling phenomenon of the PCL in ACL-deficient knees. Knee Surg Sports Traumatol Arthrosc 31:332–339. https://doi.org/10.1007/s00167-022-07145-6

    Article  PubMed  Google Scholar 

  26. Tscholl PM, Vazquez O, Boudabbous S, Billieres J, Korchi AM (2020) The influence of a meniscal bucket handle tear on the Posterior Cruciate Ligament Angle in Anterior Cruciate Ligament Rupture - A case report. Int J Surg Case Rep 75:193–197

    Article  PubMed  PubMed Central  Google Scholar 

  27. Wang D, Kent RN 3rd, Amirtharaj MJ, Hardy BM, Nawabi DH, Wickiewicz TL et al (2019) Tibiofemoral kinematics during compressive loading of the ACL-intact and ACL-sectioned knee: roles of tibial slope, medial eminence volume, and anterior laxity. J Bone Joint Surg Am 101:1085–1092

    Article  PubMed  Google Scholar 

  28. Willinger L, Athwal KK, Holthof S, Imhoff AB, Williams A, Amis AA (2023) Role of the anterior cruciate ligament, anterolateral complex, and lateral meniscus posterior root in anterolateral rotatory knee instability: a biomechanical study. Am J Sports Med 51:1136–1145

    Article  PubMed  PubMed Central  Google Scholar 

  29. Yoo JD, Lim HM (2012) Morphologic changes of the posterior cruciate ligament on magnetic resonance imaging before and after reconstruction of chronic anterior cruciate ligament ruptures. Knee Surg Relat Res 24:241–244

    Article  PubMed  PubMed Central  Google Scholar 

  30. Yoon JP, Chang CB, Yoo JH, Kim SJ, Choi JY, Choi JA et al (2010) Correlation of magnetic resonance imaging findings with the chronicity of an anterior cruciate ligament tear. J Bone Joint Surg Am 92:353–360

    Article  PubMed  Google Scholar 

  31. Zaffagnini S, Signorelli C, Bonanzinga T, Grassi A, Galan H, Akkawi I et al (2016) Does meniscus removal affect ACL-deficient knee laxity? An in vivo study. Knee Surg Sports Traumatol Arthrosc 24:3599–3604

    Article  CAS  PubMed  Google Scholar 

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Funding

No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

Author information

Authors and Affiliations

  1. Clinic for Orthopaedics and Trauma Surgery, Malteser St. Mary’s Hospital, Erlangen, Germany

    Jakub Oronowicz & Thomas Tischer

  2. Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg-Clinique d’Eich, Luxembourg, Luxembourg

    Caroline Mouton & Romain Seil

  3. Sports Medicine and Science, Luxembourg Institute of Research in Orthopaedics, Luxembourg, Luxembourg

    Caroline Mouton & Romain Seil

  4. Department of Orthopaedic Surgery, Ambroise Paré Hospital, Paris Saclay University, Paris, France

    Charles Pioger

  5. Department of Orthopaedic Surgery, Centre Hospitalier Universitaire Ambroise Paré, Mons, Belgium

    Jérôme Valcarenghi

  6. Department of Orthopaedics, University of Rostock, Rostock, Germany

    Thomas Tischer

  7. Human Motion, Orthopaedics, Sports Medicine and Digital Methods, Luxemburg Institute of Health, Luxembourg, Luxembourg

    Romain Seil

Authors
  1. Jakub Oronowicz
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  2. Caroline Mouton
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  4. Jérôme Valcarenghi
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Contributions

JO, CM and JV have made substantial contributions to conception, study design, acquisition/interpretation of data, statistical analyses and in drafting the manuscript. RS, TT and CP have been involved in the conception, study design, interpretation of data and critical revision of the manuscript. Each author has given final approval of the version to be published and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Romain Seil.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

As the study was performed in accordance with ethical standards of the institutional and national research committees, it did not require prior approval.

Informed consent

The data for this retrospective study were collected from a prospective hospital-based ACL registry. Institutional Review Board (IRB) approval was provided by the National Ethics Committee for Research in Luxemburg (notification number 201101/05) and all patients gave their written informed consent.

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Oronowicz, J., Mouton, C., Pioger, C. et al. The posterior cruciate ligament–posterior femoral cortex angle (PCL–PCA) and the lateral collateral ligament (LCL) sign are useful parameters to indicate the progression of knee decompensation over time after an ACL injury. Knee Surg Sports Traumatol Arthrosc 31, 5128–5136 (2023). https://doi.org/10.1007/s00167-023-07583-w

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