Skip to main content
SpringerLink
Log in

High prevalence of a deep lateral femoral notch sign in patients with anterior cruciate ligament (ACL) and concomitant posterior root tears of the lateral meniscus

  • KNEE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To determine the prevalence of a deep lateral femoral notch sign (LFNS) in magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) and concomitant posterior root tears of the lateral meniscus (PLRT).

Methods

A retrospective chart review was conducted to identify all patients undergoing ACL reconstruction between 2016 and 2018. Based on the arthroscopic appearance of the lateral meniscus, patients were assorted to one of three groups: isolated ACL tear (ACL-Group), ACL tear with concomitant lateral meniscus tear not involving the posterolateral root (Meniscus-Group), and ACL tear with concomitant PLRT (PLRT-Group). Incidence and depth of a LFNS on preoperative MRI was compared between the three cohorts.

Results

115 patients (mean age: 29.5 ± 11.3 years) were included in the study, with 58 patients (50.4%) assorted to the ACL-Group, 24 patients (20.9%) to the Meniscus-Group, and 33 patients (28.7%) to the PLRT-Group. The prevalence of a LFNS was significantly higher in the PLRT-Group (39.4%), when compared to the ACL- (5.2%) or Meniscus-Groups (25.0%; p < 0.001, respectively). Additionally, logistic regression analysis demonstrated that patients with PLRT were 5.3 times more likely to have a LFNS as compared to those without a lateral root tear (p < 0.001).

Conclusion

In patients with ACL tears, the presence of a LFNS on preoperative MRI may be predictive for a PLRT. As the LFNS occurs in almost 40% of the patients with combined ACL tears and PLRT, the LFNS may be a useful secondary diagnostic finding in early MRI diagnostic. Identifying PLRT on MRI is clinically relevant, as it prevents misdiagnosis and facilitates surgical decision-making, thus avoiding subsequent delayed treatment.

Level of evidence

Level IV.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Anderson L, Watts M, Shapter O, Logan M, Risebury M, Duffy D et al (2010) Repair of radial tears and posterior horn detachments of the lateral meniscus: minimum 2-year follow-up. Arthroscopy 26:1625–1632

    Article  Google Scholar 

  2. Bhatia S, LaPrade CM, Ellman MB, LaPrade RF (2014) Meniscal root tears: significance, diagnosis, and treatment. Am J Sports Med 42:3016–3030

    Article  Google Scholar 

  3. Brody JM, Lin HM, Hulstyn MJ, Tung GA (2006) Lateral meniscus root tear and meniscus extrusion with anterior cruciate ligament tear. Radiology 239:805–810

    Article  Google Scholar 

  4. Chhadia AM, Inacio MCS, Maletis GB, Csintalan RP, Davis BR, Funahashi TT (2011) Are meniscus and cartilage injuries related to time to anterior cruciate ligament reconstruction? Am J Sports Med 39:1894–1899

    Article  Google Scholar 

  5. Choi S-H, Bae S, Ji SK, Chang MJ (2012) The MRI findings of meniscal root tear of the medial meniscus: emphasis on coronal, sagittal and axial images. Knee Surg Sports Traumatol Arthrosc 20:2098–2103

    Article  Google Scholar 

  6. 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

    Article  CAS  Google Scholar 

  7. De Smet AA, Blankenbaker DG, Kijowski R, Graf BK, Shinki K (2009) MR diagnosis of posterior root tears of the lateral meniscus using arthroscopy as the reference standard. AJR Am J Roentgenol 192:480–486

    Article  Google Scholar 

  8. De Smet AA, Mukherjee R (2008) Clinical, MRI, and arthroscopic findings associated with failure to diagnose a lateral meniscal tear on knee MRI. AJR Am J Roentgenol 190:22–26

    Article  Google Scholar 

  9. Feucht MJ, Bigdon S, Mehl J, Bode G, Muller-Lantzsch C, Sudkamp NP et al (2015) Risk factors for posterior lateral meniscus root tears in anterior cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc 23:140–145

    Article  Google Scholar 

  10. Forkel P, Herbort M, Sprenker F, Metzlaff S, Raschke M, Petersen W (2014) The biomechanical effect of a lateral meniscus posterior root tear with and without damage to the meniscofemoral ligament: efficacy of different repair techniques. Arthroscopy 30:833–840

    Article  Google Scholar 

  11. Frank JM, Moatshe G, Brady AW, Dornan GJ, Coggins A, Muckenhirn KJ et al (2017) Lateral meniscus posterior root and meniscofemoral ligaments as stabilizing structures in the ACL-deficient knee: a biomechanical study. Orthop J Sports Med 5:2325967117695756

    Article  Google Scholar 

  12. Garth WP Jr, Greco J, House MA (2000) The lateral notch sign associated with acute anterior cruciate ligament disruption. Am J Sports Med 28:68–73

    Article  Google Scholar 

  13. Granan L-P, Bahr R, Lie SA, Engebretsen L (2009) Timing of anterior cruciate ligament reconstructive surgery and risk of cartilage lesions and meniscal tears: a cohort study based on the Norwegian National Knee Ligament Registry. Am J Sports Med 37:955–961

    Article  Google Scholar 

  14. Herbst E, Hoser C, Tecklenburg K, Filipovic M, Dallapozza C, Herbort M et al (2015) The lateral femoral notch sign following ACL injury: frequency, morphology and relation to meniscal injury and sports activity. Knee Surg Sports Traumatol Arthrosc 23:2250–2258

    Article  Google Scholar 

  15. Hodel S, Kabelitz M, Tondelli T, Vlachopoulos L, Sutter R, Fucentese SF (2019) Introducing the lateral femoral condyle index as a risk factor for anterior cruciate ligament injury. Am J Sports Med 47:2420–2426

    Article  Google Scholar 

  16. Hoffelner T, Pichler I, Moroder P, Osti M, Hudelmaier M, Wirth W et al (2015) Segmentation of the lateral femoral notch sign with MRI using a new measurement technique. BMC Musculoskelet Disord 16:217

    Article  Google Scholar 

  17. Kanakamedala AC, Burnham JM, Pfeiffer TR, Herbst E, Kowalczuk M, Popchak A et al (2018) Lateral femoral notch depth is not associated with increased rotatory instability in ACL-injured knees: a quantitative pivot shift analysis. Knee Surg Sports Traumatol Arthrosc 26:1399–1405

    Article  Google Scholar 

  18. Keene GC, Bickerstaff D, Rae PJ, Paterson RS (1993) The natural history of meniscal tears in anterior cruciate ligament insufficiency. Am J Sports Med 21:672–679

    Article  CAS  Google Scholar 

  19. Kim JH, Chung JH, Lee DH, Lee YS, Kim JR, Ryu KJ (2011) Arthroscopic suture anchor repair versus pullout suture repair in posterior root tear of the medial meniscus: a prospective comparison study. Arthroscopy 27:1644–1653

    Article  Google Scholar 

  20. Knapik DM, Salata MJ, Voos JE, Greis PE, Karns MR (2020) Role of the meniscofemoral ligaments in the stability of the posterior lateral meniscus root after injury in the ACL-deficient knee. JBJS Rev 8:e0071

    Article  Google Scholar 

  21. Koenig JH, Ranawat AS, Umans HR, DiFelice GS (2009) Meniscal root tears: diagnosis and treatment. Arthroscopy 25:1025–1032

    Article  Google Scholar 

  22. Kohn D, Moreno B (1995) Meniscus insertion anatomy as a basis for meniscus replacement: a morphological cadaveric study. Arthroscopy 11:96–103

    Article  CAS  Google Scholar 

  23. Krych AJ, Wu IT, Desai VS, Murthy NS, Collins MS, Saris DBF et al (2018) High rate of missed lateral meniscus posterior root tears on preoperative magnetic resonance imaging. Orthop J Sports Med 6:2325967118765722–2325967118765722

    PubMed  PubMed Central  Google Scholar 

  24. LaPrade CM, Jansson KS, Dornan G, Smith SD, Wijdicks CA, LaPrade RF (2014) Altered tibiofemoral contact mechanics due to lateral meniscus posterior horn root avulsions and radial tears can be restored with in situ pull-out suture repairs. J Bone Joint Surg Am 96:471–479

    Article  Google Scholar 

  25. LaPrade RF, Ho CP, James E, Crespo B, LaPrade CM, Matheny LM (2015) Diagnostic accuracy of 3.0 T magnetic resonance imaging for the detection of meniscus posterior root pathology. Knee Surg Sports Traumatol Arthrosc 23:152–157

    Article  Google Scholar 

  26. LaPrade RF, Matheny LM, Moulton SG, James EW, Dean CS (2017) Posterior meniscal root repairs: outcomes of an anatomic transtibial pull-out technique. Am J Sports Med 45:884–891

    Article  Google Scholar 

  27. Laundre BJ, Collins MS, Bond JR, Dahm DL, Stuart MJ, Mandrekar JN (2009) MRI accuracy for tears of the posterior horn of the lateral meniscus in patients with acute anterior cruciate ligament injury and the clinical relevance of missed tears. AJR Am J Roentgenol 193:515–523

    Article  Google Scholar 

  28. Lee YG, Shim J-C, Choi YS, Kim JG, Lee GJ, Kim HK (2008) Magnetic resonance imaging findings of surgically proven medial meniscus root tear: tear configuration and associated knee abnormalities. J Comput Assist Tomogr 32:452–457

    Article  Google Scholar 

  29. 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 

  30. 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 

  31. Matheny LM, Ockuly AC, Steadman JR, LaPrade RF (2015) Posterior meniscus root tears: associated pathologies to assist as diagnostic tools. Knee Surg Sports Traumatol Arthrosc 23:3127–3131

    Article  Google Scholar 

  32. Novaretti JV, Lian J, Patel NK, Chan CK, Cohen M, Musahl V et al (2020) Partial lateral meniscectomy affects knee stability even in anterior cruciate ligament-intact knees. J Bone Joint Surg Am. https://doi.org/10.2106/jbjs.19.00712

    Article  PubMed  Google Scholar 

  33. Pao DG (2001) The lateral femoral notch sign. Radiology 219:800–801

    Article  CAS  Google Scholar 

  34. 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 

  35. Petersen W, Forkel P, Feucht MJ, Zantop T, Imhoff AB, Brucker PU (2014) Posterior root tear of the medial and lateral meniscus. Arch Orthop Trauma Surg 134:237–255

    Article  Google Scholar 

  36. Schillhammer CK, Werner FW, Scuderi MG, Cannizzaro JP (2012) Repair of lateral meniscus posterior horn detachment lesions: a biomechanical evaluation. Am J Sports Med 40:2604–2609

    Article  Google Scholar 

  37. Seo HS, Lee SC, Jung KA (2011) Second-look arthroscopic findings after repairs of posterior root tears of the medial meniscus. Am J Sports Med 39:99–107

    Article  Google Scholar 

  38. Shelbourne KD, Roberson TA, Gray T (2011) Long-term evaluation of posterior lateral meniscus root tears left in situ at the time of anterior cruciate ligament reconstruction. Am J Sports Med 39:1439–1443

    Article  Google Scholar 

  39. Shybut TB, Vega CE, Haddad J, Alexander JW, Gold JE, Noble PC et al (2015) Effect of lateral meniscal root tear on the stability of the anterior cruciate ligament–deficient knee. Am J Sports Med 43:905–911

    Article  Google Scholar 

  40. Smith JP III, Barrett GR (2001) Medial and lateral meniscal tear patterns in anterior cruciate ligament-deficient knees: a prospective analysis of 575 tears. Am J Sports Med 29:415–419

    Article  Google Scholar 

  41. Warren R (1990) The lateral notch sign of anterior cruciate ligament insufficiency. Am J Knee Surg 1:119–124

    Google Scholar 

  42. West RV, Kim JG, Armfield D, Harner CD (2004) Lateral meniscal root tears associated with anterior cruciate ligament injury: classification and management (SS-70). Arthroscopy 20:e32–e33

    Article  Google Scholar 

Download references

Funding

No funding.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany

    Daniel P. Berthold, Lukas N. Muench, Felix Mayr, Andreas B. Imhoff & Matthias J. Feucht

  2. Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA

    Vivek Chadayammuri

  3. Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany

    Elmar Herbst

  4. Department of Orthopaedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany

    Matthias J. Feucht

Authors
  1. Daniel P. Berthold
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lukas N. Muench
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Elmar Herbst
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Felix Mayr
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Vivek Chadayammuri
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Andreas B. Imhoff
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Matthias J. Feucht
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the conception and design of the study. BDP, MF, MLN, CV. were responsible for acquisition of data and writing of the manuscript. BDP, FMJ, H E. and MN. contributed to analysis and interpretation of data. IAB and HE contributed as important reviewers of the manuscript. All authors approved the final version of this manuscript.

Corresponding author

Correspondence to Daniel P. Berthold.

Ethics declarations

Conflict of interest

Authors Berthold DP., Muench LN, Herbst E, Mayr F, Chadayammuri, V Imhoff AB, Feucht MJ declare that they have no conflict of interest.

Ethical approval

Ethical approval was obtained via Human Research Determination Form to the institutional review board (IRB) of the Technical University of Munich (IRB #606/19S).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Berthold, D.P., Muench, L.N., Herbst, E. et al. High prevalence of a deep lateral femoral notch sign in patients with anterior cruciate ligament (ACL) and concomitant posterior root tears of the lateral meniscus. Knee Surg Sports Traumatol Arthrosc 29, 1018–1024 (2021). https://doi.org/10.1007/s00167-020-06071-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-020-06071-9

Keywords

Search

Navigation