Increased internal tibiofemoral rotation is associated with anterolateral ligament injury and high‐grade pivot‐shift in anterior cruciate ligament‐injured patients
Chilan Bou Ghosson Leite, Alexander Bumberger, André Giardino Moreira da Silva, Gergő Merkely, Richard Smith, Paulo Victor Partezani Helito, Peter Asnis, Camilo Partezani Helito, Christian Lattermann
Abstract
PURPOSE: To evaluate whether tibiofemoral rotation is associated with a concurrent anterolateral ligament (ALL) injury and pivot-shift grading in patients with a primary anterior cruciate ligament (ACL) tear. METHODS: In this multicenter cross-sectional study constituting a secondary analysis of previous studies, medical records and magnetic resonance imaging (MRI) scans of patients with unilateral primary ACL injury were reviewed. Demographics and pivot-shift grading were collected. ALL was identified on MRI coronal images and categorized as intact or injured. Tibiofemoral rotation angle (TFA) was measured on axial MRI. Optimal TFA cut-off associated with ALL injury was identified by a receiver operating characteristic (ROC) curve. RESULTS: Of 206 included patients, 152 (73.8%) exhibited signs of ALL injury. Pivot-shift tests were predominantly graded as 2 (71.4%), and notably, all Grade 3 pivot-shift assessments were associated with ALL injury. Mean TFA was significantly higher in cases with ALL injury (5.2 ± 3.6°) compared to intact ALL cases (2.7 ± 3.5°; p < 0.001). A positive correlation was observed between pivot-shift grading and TFA (r = 0.204, p = 0.003). Optimal TFA cut-off value, based on the absolute measurement, for predicting ALL injury was 2.5° (sensitivity: 0.77; specificity: 0.55). Patients with TFA ≥ 2.5° had a significantly higher risk of ALL injury (odds ratio: 3.34, 95% confidence interval [CI]: 1.74-6.42, p < 0.001); when combined with pivot-shift Grade 2 or 3, this risk substantially increased to 13.68 (95% CI: 6.29-29.84, p < 0.001). CONCLUSION: Higher TFA was associated with an increased prevalence of ALL injuries and a high-grade pivot-shift in ACL-deficient patients. Patients with a TFA ≥ 2.5° showed a threefold higher likelihood of ALL injuries, and this risk further escalated with a higher-grade pivot-shift. LEVEL OF EVIDENCE: Level 3, cross-sectional study.