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The deep lateral femoral notch sign: a reliable diagnostic tool in identifying a concomitant anterior cruciate and anterolateral ligament injury

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The aim of the present study was to investigate the validity and reliability of the deep lateral femoral notch sign (DLFNS) in identifying a concomitant anterior cruciate ligament (ACL)/anterolateral ligament (ALL) rupture and predicting the clinical outcomes following an anatomical single-bundle ACL reconstruction. It was hypothesized that patients with a concomitant ACL/ALL rupture would have an increased DLFNS compared to patients without a concomitant ACL/ALL rupture.

Methods

The lateral preoperative radiographs and MRI images of 100 patients with an ACL rupture and 100 control subjects were evaluated for the presence of a DLFNS and ACL/ALL rupture, respectively. The patients were evaluated clinically preoperatively and at a minimum 1 year following the ACL reconstruction. A receiver operator curve (ROC) analysis was performed to define the optimal cut-off value of the DLFNS for identifying a concomitant ACL/ALL injury. The relative risk (RR) was also calculated to determine whether the presence of the DLFNS was a risk factor for residual instability or ACL graft rupture following an ACL reconstruction.

Results

The prevalence of DLFNS was 52% in the ACL-ruptured patients and 15% in the control group. At a minimum 1-year follow-up, 35% (6/17) of the patients with DLFNS > 1.8 mm complained of persistent instability, and an MRI evaluation demonstrated a graft re-rupture rate of 12% (2/17). In patients with a DLFNS < 1.8 mm, 8% (7/83) reported a residual instability, and the graft rupture rate was 2.4% (2/83). A DLFNS > 1.8 mm demonstrated a sensitivity of 89%, a specificity of 95%, a negative predictive value of 98%, and a positive predictive value of 89% in identifying a concomitant ACL/ALL rupture. Patients with a DLFNS > 1.8 mm had 4.2 times increased risk for residual instability and graft rupture compared to patients with a DLFNS ≤ 1.8 mm.

Conclusions

A DLFNS > 1.8 mm could be a clinically relevant diagnostic tool for identifying a concomitant ACL/ALL rupture with high sensitivity and PPV. Patients with a DLFNS > 1.8 mm should be carefully evaluated for clinical and radiological signs of a concomitant ACL/ALL rupture and treated when needed with a combined intra-articular ACL reconstruction and extra-articular tenodesis to avoid a residual rotational instability and ACL graft rupture.

Level of evidence

III.

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Funding

This research was funded by the National Natural Science Foundation of China Grant numbers [31771017 and 31972924], the Science and Technology Commission of Shanghai Municipality, Grant number [16441908700], the Innovation Research Plan supported by Shanghai Municipal Education Commission, Grant number [ZXWF082101], Key Technologies Research and Development Program, Grant numbers [2017YFC0110700, 2019YFC010262, and 2019YFC0120601], and the Interdisciplinary Program of Shanghai Jiao Tong University, Grant numbers [ZH2018QNA06, YG2017MS09].

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Authors and Affiliations

  1. Department of Orthopaedics Bürgerspital Solothurn, Schöngrünstrasse 38, 4500, Solothurn, Switzerland

    Dimitris Dimitriou, Matthias Reimond, Andreas Foesel, Bodo Baumgaertner & Naeder Helmy

  2. Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China

    Diyang Zou & Tsung-Yuan Tsai

Authors
  1. Dimitris Dimitriou
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  2. Matthias Reimond
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  3. Andreas Foesel
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  6. Tsung-Yuan Tsai
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Correspondence to Tsung-Yuan Tsai.

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The authors of this manuscript have nothing to disclose that would bias our work.

Ethical approval

The present single-center, retrospective study was approved by the authors’ institutional Internal Review Board and the ethical committee (Ethical Committee Northeast and Central Switzerland 2018-01410).

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Ethikkommission Nordwest-und Zentralschweiz: 2018-01410.

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Dimitriou, D., Reimond, M., Foesel, A. et al. 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 29, 1968–1976 (2021). https://doi.org/10.1007/s00167-020-06278-w

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