Lateral femoral notch depth is not associated with increased rotatory instability in ACL-injured knees: a quantitative pivot shift analysis

Knee Surg Sports Traumatol Arthrosc. 2018 May;26(5):1399-1405. doi: 10.1007/s00167-017-4770-9. Epub 2017 Nov 8.


Purpose: A deep lateral femoral notch (LFN) on lateral radiographs is indicative of ACL injury. Prior studies have suggested that a deep LFN may also be a sign of persistent rotatory instability and a concomitant lateral meniscus tear. Therefore, the purpose of this study was to evaluate the relationship between LFN depth and both quantitative measures of rotatory knee instability and the incidence of lateral meniscus tears. It was hypothesized that greater LFN depth would be correlated with increased rotatory instability, quantified by lateral compartment translation and tibial acceleration during a quantitative pivot shift test, and incidence of lateral meniscus tears.

Methods: ACL-injured patients enrolled in a prospective ACL registry from 2014 to 2016 were analyzed. To limit confounders, patients were only included if they had primary ACL tears, no concurrent ligamentous or bony injuries requiring operative treatment, and no previous knee injuries or surgeries to either knee. Eighty-four patients were included in the final analysis. A standardized quantitative pivot shift test was performed pre-operatively under anesthesia in both knees, and rotatory instability, specifically lateral compartment translation and tibial acceleration, was quantified using tablet image analysis software and accelerometer sensors. Standard lateral radiographs and sagittal magnetic resonance images (MRI) of the injured knee were evaluated for LFN depth.

Results: There were no significant correlations between LFN depth on either imaging modality and ipsilateral lateral compartment translation or tibial acceleration during a quantitative pivot shift test or side-to-side differences in these measurements. Patients with lateral meniscus tears were found to have significantly greater LFN depths than those without on conventional radiograph and MRI (1.0 vs. 0.6 mm, p < 0.05; 1.2 vs. 0.8 mm, p < 0.05, respectively).

Conclusion: There was no correlation between lateral femoral notch depth on conventional radiographs or MRI and quantitative measures of rotatory instability. Concomitant lateral meniscus injury was associated with significantly greater LFN depth. Based on these findings, LFN depth should not be used as an indicator of excessive rotatory instability, but may be an indicator of lateral meniscus injury in ACL-injured patients.

Level of evidence: Prognostic level IV.

Keywords: ACL; Anterior cruciate ligament; Knee; Lateral femoral notch; Lateral notch; Pivot shift; Quantitative pivot shift; Rotatory instability; Rotatory laxity.

Publication types

  • Clinical Trial

MeSH terms

  • Adolescent
  • Adult
  • Anterior Cruciate Ligament Injuries / complications*
  • Anterior Cruciate Ligament Injuries / diagnosis
  • Anterior Cruciate Ligament Injuries / pathology
  • Anterior Cruciate Ligament Injuries / physiopathology
  • Child
  • Female
  • Femur / diagnostic imaging
  • Femur / pathology*
  • Humans
  • Joint Instability / diagnosis*
  • Joint Instability / epidemiology
  • Joint Instability / etiology
  • Joint Instability / physiopathology
  • Knee Joint / diagnostic imaging
  • Knee Joint / pathology*
  • Knee Joint / physiopathology
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Prognosis
  • Prospective Studies
  • Radiography
  • Tibial Meniscus Injuries / diagnosis*
  • Tibial Meniscus Injuries / epidemiology
  • Tibial Meniscus Injuries / etiology
  • Tibial Meniscus Injuries / physiopathology
  • Young Adult