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The Reproducibility and Repeatability of Varus Stress Radiographs in the Assessment of Isolated Fibular Collateral Ligament and Grade-III Posterolateral Knee Injuries: An in Vitro Biomechanical Study

LaPrade, Robert F., MD, PhD1; Heikes, Christie, MD1; Bakker, Adam J., MS1; Jakobsen, Rune B., MD2

doi: 10.2106/JBJS.G.00979
Scientific Articles
Supplementary Content

Background: Objective measures to quantitate the amount of lateral compartment opening for patients with lateral and posterolateral knee injuries have not been well documented. The purpose of the present study was to measure lateral compartment opening secondary to applied varus stresses following posterolateral corner structure sectioning and to develop radiographic guidelines to quantify the amount of lateral compartment gapping seen with these injuries.

Methods: Ten nonpaired fresh-frozen cadaver lower extremities were used. Two varus loads, a 12-Nm moment and a clinician-applied varus stress, were applied to the intact knees and after sequential sectioning of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and anterior and posterior cruciate ligaments to simulate degrees of posterolateral knee and associated combined cruciate ligament injuries. The shortest distance between the most distal subchondral bone surface of the lateral femoral condyle and the corresponding lateral tibial plateau was measured to quantify lateral compartment opening and was analyzed on digital radiographs. Three observers were used to determine interobserver reproducibility and intraobserver repeatability.

Results: In the intact knee, the mean lateral compartment gapping due to a 12-Nm moment and a clinician-applied varus stress was 8.9 and 9.7 mm, respectively. Lateral gapping significantly increased by 2.1 and 2.7 mm in association with sectioning of the fibular collateral ligament and by 3.4 and 4.0 mm in knees with a simulated posterolateral corner injury for each respective load-application technique (p < 0.0001 for all comparisons). Intraobserver repeatability was high, with all observers independently obtaining an intraclass correlation coefficient of 0.99, whereas the analysis of interobserver reproducibility demonstrated an intraclass correlation coefficient of 0.97.

Conclusions: Measurements with use of current clinical digital imaging systems can be used to quantify the amount of lateral compartment knee opening. Clinicians should suspect an isolated fibular collateral ligament injury if opening on clinician-applied varus stress radiographs increases by approximately 2.7 mm and a grade-III posterolateral corner injury if values increase by approximately 4.0 mm.

Clinical Relevance: Varus stress radiographs appear to provide an objective and reproducible measure of lateral compartment gapping that should prove useful for the diagnosis, management, and postoperative follow-up of patients with fibular collateral ligament and posterolateral knee injuries.

aSports Medicine and Shoulder Divisions, Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue, R-200, Minneapolis, MN 55454. E-mail address for R.F. LaPrade:

bDepartment of Orthopaedic Surgery, Ullevaal University Hospital, University of Oslo, N-0407 Oslo, Norway

Copyright © 2008 by The Journal of Bone and Joint Surgery, Incorporated
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