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Characterization of the CT-based risk factors for concomitant patellofemoral instability in patients with anterior cruciate ligament injury

  • Musculoskeletal
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Abstract

Objectives

Underestimation of concomitant patellofemoral instability in patients with anterior cruciate ligament (ACL) injury has aroused extensive attention. However, the characteristics of the combined injury is not well recognized. Hence, we aimed to characterize the features of the combined injury, and determine the radiographic risk factors.

Methods

Fifteen radiological parameters were identified after discussion and pilot-tested. Radiographic measurements were compared using the analysis of variance model with Tukey post hoc analysis. A stepwise binomial logistic regression was performed and a nomogram model combining the significant risk factors was created. The model performance was validated by C-index, calibration plot, and decision curve.

Results

A total of 204 patients (mean [SD] age, 25.1 [6.7] years; 108 [52.9%] male) were included. The final model was updated through regression analysis using 4 parameters as significant risk factors: lateral femoral condyle ratio (OR (95% CI), 1.194 (1.023 to 1.409)), medial anterior tibial subluxation (mATS) (OR (95% CI), 1.234 (1.065 to 1.446)), medial posterior plateau tibial angle (mPPTA) (OR (95% CI), 1.266 (1.088 to 1.500)), and trochlear depth (OR (95% CI), 0.569 (0.397 to 0.784)). C-index for the nomogram was 0.802 (95% CI, 0.731 to 0.873) and was confirmed to be 0.784 through bootstrapping validation. Calibration plot established a good agreement between prediction and observation. Decision curve analysis showed that if threshold probability was over 10%, using the nomogram adds more benefit than either all or none scheme.

Conclusions

Lateral femoral condyle ratio, mATS, mPPTA, and trochlear depth are strong adverse predictors of patellofemoral instability in patients with ACL injury.

Clinical relevance

This study characterizes the radiological features of the combined injury. Patellofemoral instability should be noted when treating ACL injuries.

Key Points

• The radiological characteristics of the combined ACL injury and patellofemoral instability is not well recognized.

• Lateral femoral condyle ratio, mATS, mPPTA, and trochlear depth are predominant risk factors for patellofemoral instability in patients with ACL injury.

• Patellofemoral instability should be noted when treating ACL injuries.

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Abbreviations

ACL:

Anterior cruciate ligament

ACLI:

ACL injury

ACLI + PI:

ACL injury and patellofemoral instability

ANOVA:

Analysis of variance

aNWI:

Axial notch width index

CDI:

Caton-Deschamps index

CI:

Confidence interval

cNWI:

Coronal notch width index

CT:

Computed tomography

ICC:

Interclass correlation coefficient

lATS:

Lateral anterior tibial subluxation

lPPTA:

Lateral posterior plateau tibial angle

LTI:

Lateral trochlear inclination

mATS:

Medial anterior tibial subluxation

mPPTA:

Medial posterior plateau tibial angle

OR:

Odds ratio

TGM:

Trochlear groove medialization

TTL:

Tibial tubercle lateralization

TT-TG:

Tibial tubercle–trochlear groove

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Funding

This study has received funding by Shanghai Municipal Health Commission key priority discipline project; Shanghai Spinal Disease and Trauma Orthopedics Research Center, Grant No. 2022ZZ01014; Exploratory Research Program of Shanghai Sixth People’s Hospital, Grant No. YNTS202001; and Shanghai Municipal Hospital Orthopedic Specialist Alliance.

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Author notes

  1. Jiebo Chen and Xiulin Wu contributed equally to the work.

Authors and Affiliations

  1. Department of Sports Medicine, National Clinical Medical Centre of Orthopedics, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China

    Jiebo Chen, Xiulin Wu, Xueying Zhang, Jinzhong Zhao & Guoming Xie

  2. Clinical Research Center, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China

    Jingyi Guo

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  1. Jiebo Chen
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Correspondence to Jinzhong Zhao or Guoming Xie.

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The scientific guarantor of this publication is Jinzhong Zhao.

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The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors (Jingyi Guo) has significant statistical expertise.

Informed consent

Written informed consent was not required for this study because it was a retrospective study, all patients could not be identified, only basic and imaging data were collected, and the extracted data did not contain patient names.

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Institutional Review Board approval was obtained.

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  • retrospective

  • diagnostic study

  • performed at one institution

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Chen, J., Wu, X., Guo, J. et al. Characterization of the CT-based risk factors for concomitant patellofemoral instability in patients with anterior cruciate ligament injury. Eur Radiol 34, 250–259 (2024). https://doi.org/10.1007/s00330-023-10028-0

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