Skip to main content
SpringerLink
Log in

The posterior cruciate ligament index as a reliable indirect sign of anterior cruciate ligament rupture is associated with the course of knee joint injury

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

Abstract

Purpose

The objective of this study was to clarify the clinical value of the posterior cruciate ligament index (PCLI) in anterior cruciate ligament (ACL) rupture, to explore the relationship between the PCLI and course of disease, and to identify the influencing factors of the PCLI.

Methods

The PCLI was defined a quotient of the X (the tibial and femoral PCL attachments) and the Y (the maximum perpendicular distance from X to the PCL). A total of 858 patients were enrolled in this case–control study, including 433 patients with ACL ruptures who were assigned to the experimental group and 425 patients with meniscal tears (MTs) who were allocated to the control group. Some patients in the experimental group have collateral ligament rupture (CLR). Information, such as the patient’s age, sex, and course of disease, was recorded. All patients underwent magnetic resonance imaging (MRI) preoperatively, and the diagnosis was confirmed with the aid of arthroscopy. The PCLI and the depth of the lateral femoral notch sign (LFNS) were calculated based on the MRI findings, and the characteristics of the PCLI were explored.

Results

The PCLI in the experimental group (5.1 ± 1.6) was significantly smaller than that in the control group (5.8 ± 1.6) (P < 0.05). The PCLI gradually decreased with time and was only 4.8 ± 1.4 in patients in the chronic phase (P < 0.05). This change was not due to the decrease in X but rather the increase in Y. The results also showed that the PCLI was not related to the depth of the LFNS or injuries of other structures in the knee joint. Furthermore, when the optimal cut-off point of the PCLI was 5.2 (area under the curve = 71%), the specificity and the sensitivity were 84% and 67%, respectively, but the Youden index was just 0.3 (P < 0.05).

Conclusion

The PCLI decreases due to the increase in Y instead of the decrease in X with time, especially in the chronic phase. The change in X in this process may be offset during imaging. In addition, there are fewer influencing factors that lead to changes in the PCLI. Therefore, it can be used as a reliable indirect sign of ACL rupture. However, it is difficult to quantify the diagnostic criteria of the PCLI in clinical practice. Thus, the PCLI as a reliable indirect sign of ACL rupture is associated with the course of knee joint injury, and it can be used to describe the instability of the knee joint.

Levels of evidence

III.

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

Similar content being viewed by others

Availability of data and material

The datasets used or analyzed during the current study are available from the corresponding author on reasonable request.

References

  1. Berthold D, Muench L, Herbst E, Mayr F, Chadayammuri V, Imhoff A et al (2021) 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

    Article  PubMed  Google Scholar 

  2. Boeree N, Ackroyd C (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 

  3. Bonanzinga T, Grassi A, Altomare D, Lucidi G, Macchiarola L, Zaffagnini S et al (2022) High return to sport rate and few re-ruptures at long term in professional footballers after anterior cruciate ligament reconstruction with hamstrings. Knee Surg Sports Traumatol Arthrosc 30:3681–3688

    Article  PubMed  Google Scholar 

  4. Burgers PT, Den Hollander PH (2016) A typical sign on a plain knee radiograph. BMJ 355:i6021

    Article  PubMed  Google Scholar 

  5. Chen J, Xu C, Cho E, Huangfu X, Zhao J (2021) Reconstruction for chronic ACL tears with or without anterolateral structure augmentation in patients at high risk for clinical failure: a randomized clinical trial. J Bone Joint Surg Am 103:1482–1490

    Article  PubMed  Google Scholar 

  6. Diermeier T, Rothrauff B, Engebretsen L, Lynch A, Ayeni O, Paterno M et al (2020) Treatment after anterior cruciate ligament injury: panther symposium ACL treatment consensus group. Knee Surg Sports Traumatol Arthrosc 28:2390–2402

    Article  PubMed  PubMed Central  Google Scholar 

  7. Dimitriou D, Reimond M, Foesel A, Baumgaertner B, Zou D, Tsai TY et al (2020) The deep lateral femoral notch sign: a reliable diagnostic tool in identifying a concomitant anterior cruciate and anterolateral ligament injury. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-020-06278-w

    Article  PubMed  Google Scholar 

  8. Flint J, Wade A, Giuliani J, Rue J (2014) Defining the terms acute and chronic in orthopaedic sports injuries: a systematic review. Am J Sports Med 42:235–241

    Article  PubMed  Google Scholar 

  9. Gong H, Wang H, Zhang X, Fu L, Chen L (2022) Diagnostic value of the lateral femoral notch sign and kissing contusion in patients with anterior cruciate ligament injuries: a case-control study. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-022-04366-9

    Article  PubMed  Google Scholar 

  10. Hassebrock J, Gulbrandsen M, Asprey W, Makovicka J, Chhabra A (2020) Knee ligament anatomy and biomechanics. Sports Med Arthrosc Rev 28:80–86

    Article  PubMed  Google Scholar 

  11. 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  PubMed  Google Scholar 

  12. Huang H, Nagao M, Nishio H, Kaneko H, Saita Y, Takazawa Y et al (2021) Remnant preservation provides good clinical outcomes after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 29:3763–3772

    Article  PubMed  PubMed Central  Google Scholar 

  13. Huang T, Liu Z, Hong C, Wang C, Hsu K, Kuan F 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. https://doi.org/10.1186/s12891-022-05368-9

    Article  PubMed  PubMed Central  Google Scholar 

  14. Karnuta J, Dalton S, Bena J, Farrow L, Featherall J, Jones M et al (2021) Do narcotic use, physical therapy location, or payer type predict patient-reported outcomes after anterior cruciate ligament reconstruction? Orthop J Sports Med 9:2325967121994833

    PubMed  PubMed Central  Google Scholar 

  15. Kennedy M, Strauss M, LaPrade R (2020) Injury of the meniscus root. Clin Sports Med 39:57–68

    Article  PubMed  Google Scholar 

  16. Korthaus A, Warncke M, Pagenstert G, Krause M, Frosch K, Kolb JP et al (2022) Lateral femoral notch sign and posterolateral tibial plateau fractures and their associated injuries in the setting of an anterior cruciate ligament rupture. Arch Orthop Trauma Surg 142:1605–1612

    Article  PubMed  Google Scholar 

  17. Kumaki D, Tensho K, Iwaya M, Iwaasa T, Yoshida K, Koyama S et al (2022) Macroscopic and microscopic findings of multi-folded hamstring grafts of anatomical double-bundle ACL reconstruction 13 years after surgery. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-022-07185-y

    Article  PubMed  Google Scholar 

  18. LaPrade C, Civitarese D, Rasmussen M, LaPrade R (2015) Emerging updates on the posterior cruciate ligament: a review of the current literature. Am J Sports Med 43:3077–3092

    Article  PubMed  Google Scholar 

  19. Lasmar R, Marques de Almeida A, Serbino J, Mota Albuquerque R, Hernandez A (2010) Importance of the different posterolateral knee static stabilizers: biomechanical study. Clinics (Sao Paulo) 65:433–440

    Article  PubMed  Google Scholar 

  20. Liu S, Osti L, Dorey F, Yao L (1994) Anterior cruciate ligament tear. A new diagnostic index on magnetic resonance imaging. Clin Orthop 302:147–150

    Article  Google Scholar 

  21. Lucidi G, Grassi A, Di Paolo S, Agostinone P, Neri M, Macchiarola L et al (2021) The lateral femoral notch sign is correlated with increased rotatory laxity after anterior cruciate ligament injury: pivot shift quantification with a surgical navigation system. Am J Sports Med 49:649–655

    Article  PubMed  Google Scholar 

  22. Macchiarola L, Pizza N, Patania V, Grassi A, Dal Fabbro G, Marcacci M et al (2023) Double-bundle non-anatomic ACL revision reconstruction with allograft resulted in a low revision rate at 10 years. Knee Surg Sports Traumatol Arthrosc 31:340–348

    Article  PubMed  Google Scholar 

  23. Markolf K, Mensch J, Amstutz H (1976) Stiffness and laxity of the knee–the contributions of the supporting structures. A quantitative in vitro study. J Bone Joint Surg Am 58:583–594

    Article  CAS  PubMed  Google Scholar 

  24. Mather R, Koenig L, Kocher M, Dall T, Gallo P, Scott D et al (2013) Societal and economic impact of anterior cruciate ligament tears. J Bone Joint Surg Am 95:1751–1759

    Article  PubMed  PubMed Central  Google Scholar 

  25. Naraghi A, Gupta S, Jacks L, Essue J, Marks P, White L (2012) Anterior cruciate ligament reconstruction: MR imaging signs of anterior knee laxity in the presence of an intact graft. Radiology 263:802–810

    Article  PubMed  Google Scholar 

  26. Ni QK, Wang XP, Guo Q, Li M, Liu N, Zhang H (2022) High-grade pivot-shift phenomenon after anterior cruciate ligament injury is associated with asymmetry of lateral and medial compartment anterior tibial translation and lateral meniscus posterior horn tears. Knee Surg Sports Traumatol Arthrosc 30:3700–3707

    Article  PubMed  Google Scholar 

  27. Øiestad B, Engebretsen L, Storheim K, Risberg M (2009) Knee osteoarthritis after anterior cruciate ligament injury: a systematic review. Am J Sports Med 37:1434–1443

    Article  PubMed  Google Scholar 

  28. Roberts D, Ageberg E, Andersson G, Fridén T (2007) Clinical measurements of proprioception, muscle strength and laxity in relation to function in the ACL-injured knee. Knee Surg Sports Traumatol Arthrosc 15:9–16

    Article  CAS  PubMed  Google Scholar 

  29. Siwiński D, Ziemiański A (1998) Value of posterior cruciate ligament index in the diagnosis of anterior cruciate ligament injuries. Arch Orthop Trauma Surg 118:116–118

    Article  PubMed  Google Scholar 

  30. Sokal P, Norris R, Maddox T, Oldershaw R (2022) The diagnostic accuracy of clinical tests for anterior cruciate ligament tears are comparable but the Lachman test has been previously overestimated: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 30:3287–3303

    Article  PubMed  PubMed Central  Google Scholar 

  31. Theunissen W, van der Steen M, Liu W, Janssen R (2020) Timing of anterior cruciate ligament reconstruction and preoperative pain are important predictors for postoperative kinesiophobia. Knee Surg Sports Traumatol Arthrosc 28:2502–2510

    Article  CAS  PubMed  Google Scholar 

  32. Tung G, Davis L, Wiggins M, Fadale P (1993) Tears of the anterior cruciate ligament: primary and secondary signs at MR imaging. Radiology 188:661–667

    Article  CAS  PubMed  Google Scholar 

  33. von Essen C, Cristiani R, Lord L, Stålman A (2022) Subsequent surgery after primary ACLR results in a significantly inferior subjective outcome at a 2-year follow-up. Knee Surg Sports Traumatol Arthrosc 30:1927–1936

    Article  Google Scholar 

  34. Willinger L, Balendra G, Pai V, Lee J, Mitchell A, Jones M et al (2022) High incidence of superficial and deep medial collateral ligament injuries in “isolated” anterior cruciate ligament ruptures: a long overlooked injury. Knee Surg Sports Traumatol Arthrosc 30:167–175

    Article  PubMed  Google Scholar 

  35. Zakharia A, Lameire D, Abdel Khalik H, Kay J, Uddandam A, Nagai K et al (2022) Quadriceps tendon autograft for pediatric anterior cruciate ligament reconstruction results in promising postoperative function and rates of return to sports: a systematic review. Knee Surg Sports Traumatol Arthrosc 30:3659–3672

    Article  PubMed  Google Scholar 

  36. Zampeli F, Ntoulia A, Giotis D, Stavros R, Mitsionis G, Pappas E et al (2014) The PCL index is correlated with the control of rotational kinematics that is achieved after anatomic anterior cruciate ligament reconstruction. Am J Sports Med 42:665–674

    Article  PubMed  Google Scholar 

  37. Zbrojkiewicz D, Vertullo C, Grayson J (2018) Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000–2015. Med J Aust 208:354–358

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

Thanked Prof. Lin Chen for her advice and help in this study. Thanked my beloved girlfriend PhD. Danyu Chen for her contribution to this research, and will you marry me?

Funding

No funding was received to assist with the preparation of this manuscript.

Author information

Authors and Affiliations

  1. Orthopaedics, Suining Central Hospital, Suining, Sichuan, China

    Heng Gong, Qingshan Li, Yu Len, Ke He, Wenbo Zhao, Yu Li, Guanjun Sun, Xu Peng & Yi Yin

Authors
  1. Heng Gong
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Qingshan Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yu Len
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ke He
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Wenbo Zhao
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Yu Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Guanjun Sun
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Xu Peng
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Yi Yin
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

HG contributed to the article writing and data collection. QL and YL contributed to some imaging data and surgery. KH and WZ contributed to part of the statistics of the article. YL, GS and XP directed the writing of the article. YY designed the study and was responsible for the paper.

Corresponding author

Correspondence to Yi Yin.

Ethics declarations

Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethical approval

This study was approved by the ethical committee of Suining Central Hospital (LLSLH20220063).

Informed consent

Our study only involves the image information of patients. It is not necessary to obtain consent.

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 (e.g. a society or other partner) 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

Gong, H., Li, Q., Len, Y. et al. The posterior cruciate ligament index as a reliable indirect sign of anterior cruciate ligament rupture is associated with the course of knee joint injury. Knee Surg Sports Traumatol Arthrosc 31, 3277–3283 (2023). https://doi.org/10.1007/s00167-023-07357-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-023-07357-4

Keywords

Search

Navigation