Clinically Reliable Knee Flexion Angle Measured on Stress Radiography for Quantifying Posterior Instability in Posterior Cruciate Ligament Injury

Dong Jin Ryu; Kyeu Baek Kwon; Eui Yub Jung; Sung-Sahn Lee; Joo Hwan Kim; Min Chang Jang; Joon Ho Wang

doi:10.1177/2325967121989252

Clinically Reliable Knee Flexion Angle Measured on Stress Radiography for Quantifying Posterior Instability in Posterior Cruciate Ligament Injury

Orthop J Sports Med. 2021 Mar 22;9(3):2325967121989252. doi: 10.1177/2325967121989252. eCollection 2021 Mar.

Authors

Dong Jin Ryu¹, Kyeu Baek Kwon², Eui Yub Jung³, Sung-Sahn Lee⁴, Joo Hwan Kim⁵, Min Chang Jang⁵, Joon Ho Wang^{5

6

7}

Affiliations

¹ Department of Orthopaedic Surgery, Inha University Hospital, Incheon, Republic of Korea.
² Department of Orthopaedic Surgery, Saumsung Bone Hospital, Osan-si, Gyeonggi-do, Republic of Korea.
³ Department of Orthopaedic Surgery, National Medical Center, Seoul, Republic of Korea.
⁴ Department of Orthopaedic Surgery, Ilsan Paik Hospital, Inje University School of Medicine, Goyang-si, Gyeonggi-do, Republic of Korea.
⁵ Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
⁶ Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea.
⁷ Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea.

Abstract

Background: After posterior cruciate ligament injury, stress radiography is a common method of quantifying posterior instability, defined as the side-to-side difference in posterior tibial displacement (PTD) between the injured knee and contralateral noninjured knee. However, no study has evaluated the reliability of PTD according to knee flexion angle (KFA) measurements on stress radiographs.

Purpose: To evaluate the test-retest reliability of stress radiographic measurements of the KFA in the noninjured knee. In addition, we established a reliable range of KFAs to indicate posterior instability by comparing results with the instability measured at 90° KFA, which is considered the gold standard.

Study design: Cohort study (diagnosis); Level of evidence, 3.

Methods: We evaluated patients who had undergone bilateral stress radiographic examinations at least 5 times for ligament injuries between January 2013 and November 2019. All examinations were performed on a Telos device with a 150-N posterior load. A total of 120 knees and 644 stress radiographs were enrolled. We measured the KFA and PTD on stress radiographs and evaluated the reliability of repeated PTD measurement and the correlation between KFA and PTD.

Results: The distribution of the actual noninjured knee KFA ranged from 56.9° to 106.7°. Among the 644 radiographs, 155 (24.1%) showed KFAs between 85° and 95°, and 287 (44.6%) showed KFAs between 80° and 85°. A significant correlation was found between KFA and PTD (P < .001), and the intrapatient intraclass correlation coefficient (ICC) was 0.788. A KFA range of 85° to 92° satisfied the criteria of high ICC (0.885) and nonsignificant correlation between KFA and PTD (P = .055) and thus was considered a reliable range of KFAs for quantifying posterior instability. We found no significant risk factors for measurement error, including age (P = .674), sex (P = .328), height (P = .957), weight (P = .248), or body mass index (P = .257).

Conclusion: We found high reproducibility of posterior displacement measurements on Telos stress radiography at a KFA of 85° to 92° in noninjured knees.

Keywords: knee flexion angle; posterior cruciate ligament injury; posterior instability; reliability; stress radiography.