Skip to main content
SpringerLink
Log in

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

Abstract

Purpose

The aim was to validate a new MRI method to measure the buckling phenomenon of the PCL, representative of anterior tibial translation, by comparing its reliability and accuracy to identify anterior cruciate ligament (ACL)-deficient knees with existing methods.

Methods

Patients were selected retrospectively and separated into a group of primary ACL injuries and ACL-intact knees. Exclusion criteria were: skeletal immaturity, PCL or a concomitant collateral ligament injury, signs of osteoarthritis (> 1 Kellgren and Lawrence score), tibial plateau fracture, previous ACL reconstruction or displaced meniscal bucket handle tear. The assessment of the curvature of the anterolateral bundle of the PCL was performed on T2 sagittal MRI slices according to 3 methods: (1) the PCL angle (PCLA), (2) the PCL inclination angle (PCLIA) and (3) a new method: the PCL-posterior cortex angle (PCL–PCA), representing the angle between the vertical part of the PCL-ALB and the posterior diaphyseal cortex of the femur. For each method, the inter- and intra-observer reliability was measured. The ability to discriminate both ACL-deficient and ACL-intact knees was evaluated using ROC curves.

Results

Twenty-four patients were included in each group. Intra-observer reliability was excellent for all 3 methods (ICCs > 0.90). Inter-observer reliability was excellent for the PCL–PCA (ICC > 0.90) and good for the PCLA and the PCLIA (ICCs between 0.75 and 0.90). The PCL–PCA had the highest precision (lowest standard error of measurement: 2.7°). It yielded an excellent discrimination between the ACL and CTL groups (AUC 0.80 [0.67–0.93]) with the highest sensitivity (71% [52.8–89.2]) and specificity (88% [75–100]) for a positive threshold when the angle was ≤ 22.7°. The PCLA and PCLIA methods led to acceptable discrimination and lower sensitivities and specificities (PCLA: AUC 0.71, sensitivity 63%, specificity 79%, threshold ≤ 117.9°; PCLIA: AUC 0.62, sensitivity 50%, specificity 83%, threshold ≤ 21.4°).

Conclusion

In comparison with previously described methods, the PCL–PCA was the most reliable and accurate method to measure the PCL buckling phenomenon on MRI in anterior cruciate ligament (ACL)-deficient knees. It offers an easy and objective method for the follow-up of ACL-injured patients and can therefore be recommended for routine use.

Level of evidence

IV.

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

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

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
Fig. 4

Similar content being viewed by others

Explore related subjects

Discover the latest articles, news and stories from top researchers in related subjects.

References

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

    Article  CAS  Google Scholar 

  2. Celikyay F, Yuksekkaya R, Bilgic E (2020) A retrospective comparison of ACL tear and mucoid degeneration MRI findings and an emphasis on evaluating of ACL, blumensaat, and PCL angles. J Belg Soc Radiol 104:36

    Article  Google Scholar 

  3. Fluss R, Faraggi D, Reiser B (2005) Estimation of the Youden Index and its associated cutoff point. Biom J 47:458–472

    Article  Google Scholar 

  4. Gali JC, Almeida TA, de Moraes Miguel DC, Nassar SA, Filho JCG, Drain NP, Fu FF (2022) The posterior cruciate ligament inclination angle is higher in anterior cruciate ligament insufficiency. Knee Surg Sports Traumatol Arthrosc 30:124–130

    Article  Google Scholar 

  5. Gentili A, Seeger LL, Yao L, Do HM (1994) Anterior cruciate ligament tear: indirect signs at MR imaging. Radiology 193:835–840

    Article  CAS  Google Scholar 

  6. Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16:494–502

    Article  CAS  Google Scholar 

  7. Koo TK, Li MY (2016) A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med 15:155–163

    Article  Google Scholar 

  8. Lee JK, Yao L, Phelps CT, Wirth CR, Czajka J, Lozman J (1988) Anterior cruciate ligament tears: MR imaging compared with arthroscopy and clinical tests. Radiology 166:861–864

    Article  CAS  Google Scholar 

  9. Lee K, Siegel MJ, Lau DM, Hildebolt CF, Matava MJ (1999) Anterior cruciate ligament tears: MR imaging-based diagnosis in a pediatric population. Radiology 213:697–704

    Article  CAS  Google Scholar 

  10. 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  Google Scholar 

  11. Mandrekar JN (2010) Receiver operating characteristic curve in diagnostic test assessment. J Thorac Oncol 5:1315–1316

    Article  Google Scholar 

  12. McCauley TR, Moses M, Kier R, Lynch JK, Barton JW, Jokl P (1994) MR diagnosis of tears of anterior cruciate ligament of the knee: importance of ancillary findings. Am J Roentgenol 162:115–119

    Article  CAS  Google Scholar 

  13. Mehl J, Otto A, Baldino JB, Achtnich A, Akoto R, Imhoff AB, Scheffler S, Petersen W (2019) The ACL-deficient knee and the prevalence of meniscus and cartilage lesions: a systematic review and meta-analysis (CRD42017076897). Arch Orthop Trauma Surg 139:819–841

    Article  Google Scholar 

  14. Mellado JM, Calmet J, Olona M, Giné J, Saurí A (2004) Magnetic resonance imaging of anterior cruciate ligament tears: reevaluation of quantitative parameters and imaging findings including a simplified method for measuring the anterior cruciate ligament angle. Knee Surg Sports Traumatol Arthrosc 12:217–224

    Article  CAS  Google Scholar 

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

    Article  CAS  Google Scholar 

  16. Polat A, Acar N, Aybar A, Fidan F, Özden E, Gürkan O (2021) The correlation between posterior cruciate ligament buckling sign and meniscofemoral ligaments: a radiological study. Jt Dis Relat Surg 32:371–376

    Article  Google Scholar 

  17. Robertson PL, Schweitzer ME, Bartolozzi AR, Ugoni A (1994) Anterior cruciate ligament tears: evaluation of multiple signs with MR imaging. Radiology 193:829–834

    Article  CAS  Google Scholar 

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

    Article  Google Scholar 

  19. 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  Google Scholar 

  20. Seil R, Cucchi D, Ninulescu C, Dor J, Mouton C (2019) Anatomic anterior cruciate ligament reconstruction for adolescent patients with open physis. Ann Jt 4:31

    Article  Google Scholar 

  21. Tung GA, Davis LM, Wiggins ME, Fadale PD (1993) Tears of the anterior cruciate ligament: primary and secondary signs at MR imaging. Radiology 188:661–667

    Article  CAS  Google Scholar 

  22. Van Dyck P, Gielen JL, Vanhoenacker FM, Wouters K, Dossche L, Parizel PM (2012) Stable or unstable tear of the anterior cruciate ligament of the knee: an MR diagnosis? Skelet Radiol 41:273–280

    Article  Google Scholar 

  23. 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  Google Scholar 

  24. Yoon JP, Chang CB, Yoo JH, Kim SJ, Choi JY, Choi J-A, Seong SC, Kim TK (2010) Correlation of magnetic resonance imaging findings with the chronicity of an anterior cruciate ligament tear. J Bone Jt Surg Am 92:353–360

    Article  Google Scholar 

  25. Yoon JP, Yoo JH, Chang CB, Kim SJ, Choi JY, Yi JH, Kim TK (2013) Prediction of chronicity of anterior cruciate ligament tear using MRI findings. Clin Orthop Surg 5:19–25

    Article  Google Scholar 

Download references

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. Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg-Clinique d’Eich, 78 Rue d’Eich, 1460, Luxembourg, Luxembourg

    Renaud Siboni, Charles Pioger, Caroline Mouton & Romain Seil

  2. Department of Orthopaedic Surgery, Reims Teaching Hospital, Hôpital Maison Blanche, 45 Rue Cognacq-Jay, 51092, Reims, France

    Renaud Siboni

  3. Department of Orthopaedic Surgery, Ambroise Paré Hospital, Paris Saclay University, 9, avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France

    Charles Pioger

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

    Caroline Mouton & Romain Seil

  5. Human Motion, Orthopaedics, Sports Medicine and Digital Methods, Luxembourg, Luxembourg

    Romain Seil

Authors
  1. Renaud Siboni
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Charles Pioger
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Caroline Mouton
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Romain Seil
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

RSi and CP have made substantial contributions to conception, study design, acquisition/interpretation of data, and in drafting the manuscript. CM and RSe 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.

Ethics declarations

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 the medical records of patients which were obtained for routine clinical purposes. All data were exported anonymously by the team of clinicians taking care of the included patients who therefore were granted access to their medical records.

Additional information

Publisher's Note

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

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Siboni, R., Pioger, C., Mouton, C. et al. 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 (2023). https://doi.org/10.1007/s00167-022-07145-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-022-07145-6

Keywords

Search

Navigation