Stress Radiographs in the Posterior Drawer Position at 90° Flexion Should Be Used for the Evaluation of the PCL in CR TKA with Flexion Instability

Abstract

The purpose of this study was to define a cut-off value for the posterior drawer position in stress radiography that confirms an insufficiency of the posterior cruciate ligament (PCL) in cruciate-retaining (CR) total knee arthroplasty (TKA). In this retrospective study, 20 symptomatic patients with flexion instability and suspected PCL insufficiency in CR TKA were included. Asymptomatic patients served as an age- and sex-matched control group. All of the patients had undergone stress radiography, and the posterior translation was measured in a posterior drawer position at 30° and 90° flexion. The two groups were compared using t-tests and chi-square tests. The stress radiographs showed significantly more posterior translation in the symptomatic group (p < 0.01). Stress radiographs at 90° flexion more effectively discriminated between the patients with and without PCL insufficiency compared with those carried out at 30° flexion. Sensitivity and specificity testing revealed the best sensitivity (90.5%) and the best specificity (94.7%) at 90° posterior drawer radiographs at a cut-off value of 10 mm. Stress radiographs including the posterior drawer position at 90° flexion should be part of the diagnostic algorithm in patients with suspected flexion instability. A posterior translation of more than 10 mm in CR TKA strongly indicates an insufficiency of the PCL.

Keywords: CR; PCL; TKA; cruciate retaining; flexion instability; posterior cruciate ligament; stress radiographs; total knee arthroplasty.

Figure 1

Measurement technique of the posterior tibial translation in stress radiographs in approximately the 90° posterior drawer position.

Figure 2

Distribution of the PTT of the patients (cross) and the control group (circle). There is a better discrimination between both groups at 90°, indicating a cut-off value at 10 mm.