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Does Landmark Selection Affect the Reliability of Tibial Tubercle–Trochlear Groove Measurements Using MRI?

  • Clinical Research
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

A lateralized tibial tubercle is one potential cause of patellar instability. The tibial tubercle–trochlear groove (TT-TG) distance using CT is a reliable measure and considered the gold standard. Using MRI for this purpose has increased, although the reliability of doing so is not well studied.

Questions/purposes

We sought to (1) determine variability in the insertion of the patellar tendon relative to the tibial tubercle and whether this affects the measurement on MRI of the traditional TT-TG distance versus the functional patellar tendon-trochlear groove (PT-TG) distance, (2) determine the reliability of measuring the osseous TT-TG distance, (3) determine the reliability of measuring the soft tissue PT-TG distance, and (4) compare the reliabilities of using osseous (TT-TG) versus soft tissue (PT-TG) landmarks.

Methods

Four observers measured the TT-TG and the PT-TG distances of 50 MR images of knees obtained for any reason. Each observer repeated these measurements 30 days later. The interobserver and intraobserver reliabilities, measurements per observer that varied from the group mean by greater than 2 mm, and the limit of agreement were calculated.

Results

The TT-TG and PT-TG differed by as little as 0.11 mm and by as much as 4.18 mm with an average difference of 1.37 mm. The interobserver and intraobserver reliabilities were greater than 90% for the PT-TG and TT-TG distances. The PT-TG distance was less variable in that this measurement showed interobserver and intraobserver reliabilities of 0.977 and 0.972 respectively, versus 0.913 and 0.961 for the TT-TG measurement. Additionally, the PT-TG measurements resulted in a lower average difference to the mean for each observer, less number of knees per observer where the difference to the mean was greater than 2 mm, and improved limit of agreement.

Conclusions

The TT-TG and the PT-TG distances were not identical and differed by as much as 4.18 mm; as such they are not interchangeable when measuring this distance. Both methods are reliable for measuring lateral offset of the extensor mechanism, but the use of soft tissue landmarks is less variable and thus would provide a more reliable measurement for surgical planning.

Level of Evidence

Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

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References

  1. Alemparte J, Ekdahl M, Burnier L, Hernandez R, Cardemil A, Cielo R, Danilla S. Patellofemoral evaluation with radiographs and computed tomography scans in 60 knees of asymptomatic subjects. Arthroscopy. 2007;23:170–177.

    Article  PubMed  Google Scholar 

  2. Balcarek P, Ammon J, Frosch S, Walde TA, Schuttrumpf JP, Ferlemann KG, Lill H, Sturmer KM, Frosch KH. Magnetic resonance imaging characteristics of the medial patellofemoral ligament lesion in acute lateral patellar dislocations considering trochlear dysplasia, patella alta, and tibial tuberosity-trochlear groove distance. Arthroscopy. 2010;26:926–935.

    Article  PubMed  Google Scholar 

  3. Balcarek P, Jung K, Ammon J, Walde TA, Frosch S, Schuttrumpf JP, Sturmer KM, Frosch KH. Anatomy of lateral patellar instability: trochlear dysplasia and tibial tubercle-trochlear groove distance is more pronounced in women who dislocate the patella. Am J Sports Med. 2010;38:2320–2327.

    Article  PubMed  Google Scholar 

  4. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986;1:307–310.

    Article  PubMed  CAS  Google Scholar 

  5. Cox JS. Evaluation of the Roux-Elmslie-Trillat procedure for knee extensor realignment. Am J Sports Med. 1982;10:303–310.

    Article  PubMed  CAS  Google Scholar 

  6. Davies AP, Costa ML, Shepstone L, Glasgow MM, Donell S. The sulcus angle and malalignment of the extensor mechanism of the knee. J Bone Joint Surg Br. 2000;82:1162–1166.

    Article  PubMed  CAS  Google Scholar 

  7. Dejour H, Walch G, Nove-Josserand L, Guier C. Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc. 1994;2:19–26.

    Article  PubMed  CAS  Google Scholar 

  8. Diks MJ, Wymenga AB, Anderson PG. Patients with lateral tracking patella have better pain relief following CT-guided tuberosity transfer than patients with unstable patella. Knee Surg Sports Traumatol Arthrosc. 2003;11:384–388.

    Article  PubMed  CAS  Google Scholar 

  9. Fithian DC, Paxton EW, Stone ML, Silva P, Davis DK, Elias DA, White LM. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med. 2004;32:1114–1121.

    Article  PubMed  Google Scholar 

  10. Fulkerson JP. Anteromedialization of the tibial tuberosity for patellofemoral malalignment. Clin Orthop Relat Res. 1983;177:176–181.

    PubMed  Google Scholar 

  11. Hawkins RJ, Bell RH, Anisette G. Acute patellar dislocations: the natural history. Am J Sports Med. 1986;14:117–120.

    Article  PubMed  CAS  Google Scholar 

  12. Koeter S, Diks MJ, Anderson PG, Wymenga AB. A modified tibial tubercle osteotomy for patellar maltraking: results at two years. J Bone Joint Surg Br. 2007;89:180–185.

    Article  PubMed  CAS  Google Scholar 

  13. Koeter S, Hortsmann WG, Wagenaar FC, Huysse W, Wymenga AB, Anderson PG. A new CT scan method for measuring the tibial tubercle trochlear groove distance in patellar instability. Knee. 2007;14:128–132.

    Article  PubMed  Google Scholar 

  14. Koskinen SK, Taimela S, Nelimarkka O, Komu M, Jujala UM. Magnetic resonance imaging of patellofemoral relationships. Skeletal Radiol. 1993; 22:403–410.

    Article  PubMed  CAS  Google Scholar 

  15. Kujala UM, Osterman K, Kormano M, Nelimarkka O, Hurme M, Taimela S. Patellofemoral relationships in recurrent patellar dislocation. J Bone Joint Surg Br. 1989;71:788–792.

    PubMed  CAS  Google Scholar 

  16. Lustig S, Servien E, Ait Si Selmi T, Neyret P. [Factors affecting the reliability of TT-TG measurements before and after medialization: a CT scan study] [in French]. Rev Chir Orthop Reparatrice Appar Mot. 2006;92:429–436.

    Article  PubMed  CAS  Google Scholar 

  17. Maquet P. Advancement of the tibial tuberosity. Clin Orthop Relat Res. 1976;115:225–230.

    PubMed  Google Scholar 

  18. Post WR, Fulkerson JP. Distal realignment of the patellofemoral joint: indications, effects, results, and recommendations. Orthop Clin North Am. 1992;23:631–643.

    PubMed  CAS  Google Scholar 

  19. Saudan M, Fritschy D. [AT-TG (anterior tuberosity-trochlear groove): interobserver variability in CT measurements in subjects with patellar instability] [in French]. Rev Chir Orthop Reparatrice Appar Mot. 2000;86:250–255.

    PubMed  CAS  Google Scholar 

  20. Schoettle PB, Zanetti M, Seifert B, Pfirrmann CW, Fucentese SF, Romero J. The tibial tuberosity-trochlear groove distance: a comparative study between CT and MRI scanning. Knee. 2006;13:26–31.

    Article  PubMed  Google Scholar 

  21. Shakespeare D, Fick D. Patellar instability: can the TT-TG distance be measured clinically? Knee. 2005;12:201–204.

    Article  PubMed  Google Scholar 

  22. Shih YE, Bull AM, Amis AA. The cartilaginous and osseous geometry of femoral trochlear groove. Knee Surg Sports Traumatol Arthrosc. 2004;12:300–306.

    Article  PubMed  Google Scholar 

  23. Smith TO, Davies L, Toms AP, Hing CB, Donell ST. The reliability and validity of radiological assessment for patellar instability: a systematic review and meta-analysis. Skeletal Radiol. 2011;40:399–414.

    Article  PubMed  Google Scholar 

  24. Staubli HU, Bosshard C, Porcellini P, Rauschning W. Magnetic resonance imaging for articular cartilage: cartilage-bone mismatch. Clin Sports Med. 2002;21:417–433, viii–ix.

    Article  Google Scholar 

  25. Staubli HU, Durrenmatt U, Porcellini P, Rauschning W. Anatomy and surface geometry of the patellofemoral joint in the axial plane. J Bone Joint Surg Br. 1999;81:452–458.

    Article  PubMed  CAS  Google Scholar 

  26. Toms AP, Cahir J, Swift L, Donell ST. Imaging the femoral sulcus with ultrasound, CT, and MRI: reliability and generalizability in patients with patellar instability. Skeletal Radiol. 2009;38:329–338.

    Article  PubMed  Google Scholar 

  27. Vahasarja V, Lanning P, Lahde S, Serlo W. Axial radiography or CT in the measurement of patellofemoral malalignment indices in children and adolescents? Clin Radiol. 1996;51:639–643.

    Article  PubMed  CAS  Google Scholar 

  28. van Huyssteen AL, Hendrix MR, Barnett AJ, Wakeley CJ, Eldridge JD. Cartilage-bone mismatch in the dysplastic trochlea: an MRI study. J Bone Joint Surg Br. 2006;88:688–691.

    Article  PubMed  Google Scholar 

  29. Wagenaar FC, Koeter S, Anderson PG, Wymenga AB. Conventional radiography cannot replace CT scanning in detecting tibial tubercle lateralisation. Knee. 2007;14:51–54.

    Article  PubMed  Google Scholar 

  30. Wittstein JR, Bartlett EC, Easterbrook J, Byrd JC. Magnetic resonance imaging evaluation of patellofemoral malalignment. Arthroscopy. 2006;22:643–649.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA

    Jason J. Wilcox MD

  2. Snow Orthopaedics, McKinney, TX, USA

    Brian J. Snow MD

  3. Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA

    Stephen K. Aoki MD, Man Hung PhD & Robert T. Burks MD

Authors
  1. Jason J. Wilcox MD
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  2. Brian J. Snow MD
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  3. Stephen K. Aoki MD
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  4. Man Hung PhD
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  5. Robert T. Burks MD
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Corresponding author

Correspondence to Jason J. Wilcox MD.

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Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at the University of Utah Orthopaedic Center, Salt Lake City, UT, USA.

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Wilcox, J.J., Snow, B.J., Aoki, S.K. et al. Does Landmark Selection Affect the Reliability of Tibial Tubercle–Trochlear Groove Measurements Using MRI?. Clin Orthop Relat Res 470, 2253–2260 (2012). https://doi.org/10.1007/s11999-012-2269-8

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  • DOI: https://doi.org/10.1007/s11999-012-2269-8

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