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Validating the Role of Tibial Tubercle–Posterior Cruciate Ligament Distance and Tibial Tubercle–Trochlear Groove Distance Measured by Magnetic Resonance Imaging in Patients With Patellar Dislocation: A Diagnostic Study

Published:September 16, 2020DOI:https://doi.org/10.1016/j.arthro.2020.09.004

      Purpose

      To (1) compare these parameters between patients with patellar dislocation and healthy individuals on magnetic resonance imaging measurements, (2) validate the diagnostic capacity of the tibial tubercle–posterior cruciate ligament (TT-PCL) distance and tibial tubercle–trochlear groove (TT-TG) distance, (3) define the pathologic threshold values of these parameters for tibial tubercle osteotomy indication, and (4) compare these values with those of previous studies.

      Methods

      Seventy patients with patellar dislocation and 70 healthy volunteers were identified. The inter- and intraobserver reliability values were determined using Bland–Altman analysis and the intraclass correlation coefficient (ICC). The diagnostic capacity of the parameters was evaluated using receiver operating characteristic curves and the area under the receiver operating characteristic curve. The data of the control group were used to determine the pathologic threshold values of the measurements. Logistic regression analysis was performed with these pathologic threshold values.

      Results

      Significant differences in the TT-PCL distance (P = .01) and TT-TG distance (P < .001) were found between the study group (21.48 ± 3.18 and 12.91 ± 3.80, respectively) and the control group (20.07 ± 2.99 and 8.46 ± 3.16, respectively). Both the TT-PCL distance and TT-TG distance had excellent inter- and intraobserver agreement, with inter-ICCs >0.915 and intra-ICCs >0.932, respectively. However, the TT-TG distance had a higher area under the receiver operating characteristic curve than did the TT-PCL distance (0.820 vs 0.627). The pathologic threshold value of the TT-PCL distance was 24.76 mm. The pathologic threshold value of the TT-TG distance was 13.64 mm. Subjects with a TT-TG distance of >13.64 mm had a greater risk for patellar dislocation, with an odds ratio of 14.02 (95% confidence interval 4.00-49.08, P < .001).

      Conclusions

      Both the TT-PCL distance and TT-TG distance can be measured reliably by magnetic resonance imaging; however, the TT-TG distance has a better diagnostic capacity than does the TT-PCL distance.

      Level of Evidence

      Retrospective cohort study (diagnosis); Level of evidence, I.
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      References

        • 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
        • Anley C.M.
        • Morris G.V.
        • Saithna A.
        • James S.L.
        • Snow M.
        Defining the role of the tibial tubercle-trochlear groove and tibial tubercle-posterior cruciate ligament distances in the work-up of patients with patellofemoral disorders.
        Am J Sports Med. 2015; 43: 1348-1353
        • Camp C.L.
        • Heidenreich M.J.
        • Dahm D.L.
        • Stuart M.J.
        • Levy B.A.
        • Krych A.J.
        Individualizing the tibial tubercle-trochlear groove distance: Patellar instability ratios that predict recurrent instability.
        Am J Sports Med. 2016; 44: 393-399
        • Heidenreich M.J.
        • Camp C.L.
        • Dahm D.L.
        • Stuart M.J.
        • Levy B.A.
        • Krych A.J.
        The contribution of the tibial tubercle to patellar instability: Analysis of tibial tubercle-trochlear groove (TT-TG) and tibial tubercle-posterior cruciate ligament (TT-PCL) distances.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 2347-2351
        • Camp C.L.
        • Stuart M.J.
        • Krych A.J.
        • et al.
        CT and MRI measurements of tibial tubercle-trochlear groove distances are not equivalent in patients with patellar instability.
        Am J Sports Med. 2013; 41: 1835-1840
        • Schoettle P.B.
        • Zanetti M.
        • Seifert B.
        • Pfirrmann C.W.
        • Fucentese S.F.
        • Romero J.
        The tibial tuberosity-trochlear groove distance; a comparative study between CT and MRI scanning.
        Knee. 2006; 13: 26-31
        • Brady J.M.
        • Sullivan J.P.
        • Nguyen J.
        • et al.
        The tibial tubercle-to-trochlear groove distance is reliable in the setting of trochlear dysplasia, and superior to the tibial tubercle-to-posterior cruciate ligament distance when evaluating coronal malalignment in patellofemoral instability.
        Arthroscopy. 2017; 33: 2026-2034
        • Vairo G.L.
        • Moya-Angeler J.
        • Siorta M.A.
        • Anderson A.H.
        • Sherbondy P.S.
        Tibial tubercle-trochlear groove distance is a reliable and accurate indicator of patellofemoral instability.
        Clin Orthop Relat Res. 2019; 477: 1450-1458
        • Marquez-Lara A.
        • Andersen J.
        • Lenchik L.
        • Ferguson C.M.
        • Gupta P.
        Variability in patellofemoral alignment measurements on MRI: Influence of knee position.
        AJR Am J Roentgenol. 2017; 208: 1097-1102
        • Dietrich T.J.
        • Betz M.
        • Pfirrmann C.W.A.
        • Koch P.P.
        • Fucentese S.F.
        End-stage extension of the knee and its influence on tibial tuberosity-trochlear groove distance (TTTG) in asymptomatic volunteers.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 214-218
        • Dornacher D.
        • Reichel H.
        • Lippacher S.
        Measurement of tibial tuberosity-trochlear groove distance: evaluation of inter- and intraobserver correlation dependent on the severity of trochlear dysplasia.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 2382-2387
        • Nha K.
        • Nam Y.J.
        • Shin M.J.
        • et al.
        Referencing the trochlear groove based on three-dimensional computed tomography imaging improves the reliability of the measurement of the tibial tuberosity-trochlear groove distance in patients with higher grades of trochlea dysplasia.
        Knee. 2019; 26: 1429-1436
        • Seitlinger G.
        • Scheurecker G.
        • Hogler R.
        • Labey L.
        • Innocenti B.
        • Hofmann S.
        Tibial tubercle-posterior cruciate ligament distance: A new measurement to define the position of the tibial tubercle in patients with patellar dislocation.
        Am J Sports Med. 2012; 40: 1119-1125
        • Boutris N.
        • Delgado D.A.
        • Labis J.S.
        • McCulloch P.C.
        • Lintner D.M.
        • Harris J.D.
        Current evidence advocates use of a new pathologic tibial tubercle-posterior cruciate ligament distance threshold in patients with patellar instability.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 2733-2742
        • Lippacher S.
        • Dejour D.
        • Elsharkawi M.
        • et al.
        Observer agreement on the Dejour trochlear dysplasia classification: A comparison of true lateral radiographs and axial magnetic resonance images.
        Am J Sports Med. 2012; 40: 837-843
        • Dejour D.
        • Le Coultre B.
        Osteotomies in patello-femoral instabilities.
        Sports Med Arthrosc Rev. 2007; 15: 39-46
        • Shrout P.E.
        • Fleiss J.L.
        Intraclass correlations: Uses in assessing rater reliability.
        Psychol Bull. 1979; 86: 420-428
        • Bland J.M.
        • Altman D.G.
        Measuring agreement in method comparison studies.
        Stat Methods Med Res. 1999; 8: 135-160
        • Sgroi M.
        • Loitsch T.
        • Reichel H.
        • Kappe T.
        Diagnostic value of clinical tests for infraspinatus tendon tears.
        Arthroscopy. 2019; 35: 1339-1347
        • Xu Z.
        • Zhang H.
        • Chen J.
        • Mohamed S.I.
        • Zhou A.
        Femoral anteversion is related to tibial tubercle-trochlear groove distance in patients with patellar dislocation.
        Arthroscopy. 2020; 36: 1114-1120
        • Mistovich R.J.
        • Urwin J.W.
        • Fabricant P.D.
        • Lawrence J.T.R.
        Patellar tendon-lateral trochlear ridge distance: A novel measurement of patellofemoral instability.
        Am J Sports Med. 2018; 46: 3400-3406
        • Kaplan D.J.
        • Samim M.
        • Burke C.J.
        • Meislin R.J.
        • Youm T.
        Validity of magnetic resonance imaging measurement of hip labral width compared with intraoperative assessment.
        Arthroscopy. 2020; 36: 751-758
        • Xu Z.
        • Zhang H.
        • Fu B.
        • Mohamed S.I.
        • Zhang J.
        • Zhou A.
        Tibial tubercle-roman arch distance: A new measurement of patellar dislocation and indication of tibial tubercle osteotomy.
        Orthop J Sports Med. 2020; 8 (2325967120914872)
        • Tensho K.
        • Shimodaira H.
        • Akaoka Y.
        • et al.
        lateralization of the tibial tubercle in recurrent patellar dislocation: Verification using multiple methods to evaluate the tibial tubercle.
        J Bone Joint Surg Am. 2018; 100 (e58-e58)
        • Redler L.H.
        • Meyers K.N.
        • Brady J.M.
        • Dennis E.R.
        • Nguyen J.T.
        • Shubin Stein B.E.
        Anisometry of medial patellofemoral ligament reconstruction in the setting of increased tibial tubercle-trochlear groove distance and patella alta.
        Arthroscopy. 2018; 34: 502-510
        • Dejour D.
        • Le Coultre B.
        Osteotomies in patello-femoral instabilities.
        Sports Med Arthrosc Rev. 2018; 26: 8-15
        • Balcarek P.
        • Jung K.
        • Ammon J.
        • et al.
        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
        • Balcarek P.
        • Jung K.
        • Frosch K.H.
        • Sturmer K.M.
        Value of the tibial tuberosity-trochlear groove distance in patellar instability in the young athlete.
        Am J Sports Med. 2011; 39: 1756-1761
        • Tompkins M.A.
        • Rohr S.R.
        • Agel J.
        • Arendt E.A.
        Anatomic patellar instability risk factors in primary lateral patellar dislocations do not predict injury patterns: An MRI-based study.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 677-684
        • Hinckel B.B.
        • Gobbi R.G.
        • Filho E.N.
        • et al.
        Are the osseous and tendinous-cartilaginous tibial tuberosity-trochlear groove distances the same on CT and MRI?.
        Skeletal Radiol. 2015; 44: 1085-1093
        • Heidenreich M.J.
        • Sanders T.L.
        • Hevesi M.
        • et al.
        Individualizing the tibial tubercle to trochlear groove distance to patient specific anatomy improves sensitivity for recurrent instability.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 2858-2864