Arch Orthop Trauma Surg (1991) 110:200-203

Ach-o,Orthopaedic andTrauma Surgery

Springer-Verlag 1991

Clinical and experimental forum

Ultrasound diagnosis of pathology of the anterior and posterior cruciate ligaments of the knee joint
S. Suzuki 1, K. Kasahara 1, T. Futami 1, R. Iwasaki 2, T. Ueo 2, and T. Yamamuro 2
1Medical Center for Children in Shiga, Japan 2Kyoto University Medical School, Kyoto, Japan

Summary. W e e s t a b l i s h e d a m e t h o d of d i a g n o s i n g p a t h o logic c o n d i t i o n s of b o t h t h e a n t e r i o r c r u c i a t e l i g a m e n t ( A C L ) a n d t h e p o s t e r i o r cruciate l i g a m e n t ( P C L ) b y using u l t r a s o u n d . N o r m a l A C L a n d P C L w e r e d e l i n e a t e d as h y p e r e c h o i c i m a g e s on t h e s c r e e n in sagittal a n d transv e r s e sections. O n the o t h e r h a n d , no i m a g e o f t h e ligam e n t c o u l d b e seen w h e n t h e l i g a m e n t was r u p t u r e d . W e e x a m i n e d nine A C L a n d five P C L injuries b y o u r m e t h od. This is a safe a n d an effective m e t h o d of d e t e r m i n i n g t h e r u p t u r e of A C L a n d P C L .

U l t r a s o u n d has so far b e e n less p o p u l a r as a n o n - i n v a s i v e d i a g n o s t i c t o o l in the field of o r t h o p e d i c s t h a n in o t h e r specialties. H o w e v e r , it d o e s n o t r e q u i r e a n e s t h e s i a , n o r d o e s it d e m a n d any a s e p t i c p r o c e d u r e . This is t h e r e p o r t of t h e results of e x a m i n a t i o n o f t h e a n t e r i o r and p o s t e r i o r cruciate ligaments ( A C L a n d P C L ) b y the use of u l t r a s o u n d . A l t h o u g h L a i n e et al. d e m o n s t r a t e d a n o r m a l A C L b y u l t r a s o u n d [4], to o u r k n o w l e d g e t h e r e h a v e b e e n no r e p o r t s o n the diagnosis of r u p ture of t h e A C L a n d P C L b y m e a n s o f u l t r a s o u n d .

In order to examine the ACL, the knee joint was flexed more than 90 during maximum internal rotation (Fig. 1). When the sagittal section of the right ACL was screened, the transducer was placed on the medial-infrapatellar spot in line with the axis of tibia through the sonoconductor, and the transducer was then rotated about 30 counterclockwise. After that the transducer was inclined on the sonoconductor so that the probe would be parallel to the fibers of the ACL. To obtain horizontal section of the right ACL, the transducer was placed on the patellar tendon horizontal to the axis of the tibia, and then the transducer was rotated about 30 counterclockwise. In order to obtain the sagittal section of the right PCL, the transducer was placed on the center of the knee in line with the axis of the tibia and then rotated about 30 counterclockwise (Fig. 2). The entire section was imaged from the origin at the lateral aspect of the medial condyle of the femur to the insertion at the posterior intercondylar fossa of the tibia. To obtain the horizontal section of the right PCL, the transducer was placed at a right angle to the axis of the tibia and then rotated about 30 counterclockwise. When patients with injured knee joints or a history of trauma to the knee joint came to our hospital, they were all examined by

Patients and methods

The methods of examination of ACL and PCL was studied in one normal knee joint obtained from an amputated limb and two knee joints taken from two cadavers. In ten joints treated by arthroscopic surgery for meniscal rupture or shelf syndrome, each normal ACL with the probe attached to it was identified by ultrasound. Thus, the method of examination of ACL and PCL by ultrasound was established. Ultrasound examinations were done with a Shimazu SDU-500, at 5.0 MHz or 7.5MHz, based on both a linear and a convex electronic scanning method.
Offprint requests to: Dr. Shigeo Suzuki, Department of Orthopedics, Medical Center for Children in Shiga, 120-6, Moriyamacho, Moriyama, Shiga 524, Japan

Fig. 1. Method for obtaining sagittal section of the anterior cruciate ligament

S. Suzuki et al.: Ultrasound diagnosis of cruciate ligaments

201 s h o w n in Fig. 3a, b. T h e h o r i z o n t a l section of n o r m a l A C L c o u l d r e a d i l y b e d e m o n s t r a t e d as a h y p e r e c h o i c i m a g e (Fig. 4a, b). It was s h o w n t h a t t h e A C L c o n s i s t e d of s o m e small b u n d l e s .

Ruptured A CL
N o h y p e r e c h o i c i m a g e of t h e l i g a m e n t was seen in t h e r u p t u r e d A C L with e i t h e r a sagittal o r a h o r i z o n t a l app r o a c h . W h e n the r u p t u r e was partial, t h e cross-sectional a r e a was s m a l l e r t h a n on t h e n o r m a l side.

Normal PCL
F i g u r e 5a, b d e m o n s t r a t e s t h e s o n o g r a m of the sagittal s e c t i o n o f n o r m a l P C L . T h e e n t i r e l e n g t h of t h e P C L was s h o w n as a high e c h o i c i m a g e . F i g u r e 6a, b is t h e horiz o n t a l section of t h e P C L close to t h e i n s e r t i o n to t h e tibia.

Fig. 2. Method for obtaining sagittal section of the posterior cruelate ligament
ultrasound, and the diagnosis thus obtained was documented. After that, clinical examination was done. In patients who had abnormal findings on ultrasound examination or a positive drawer sign, arthroscopy was performed. On ultrasound examination rupture of the ACL was suspected in 9 cases (Table 1) and rupture of the PCL in 5. They were all examined by arthroscopy (Table 2). One hundred normal knees of 50 persons were studied for control.

Ruptured PCL
In t h e r u p t u r e d P C L , u l t r a s o u n d d e m o n s t r a t e d t h e interr u p t i o n o f t h e l i g a m e n t span. F i g u r e 7 shows t h e i n t e r r u p t i o n s close to t h e i n s e r t i o n into the i n t e r c o n d y l a r fossa. T h e P C L lost its t e n s i o n a n d t h e r e was no h y p e r e c h o i c figure such as is s e e n in a n o r m a l P C L . In t h e h o r i z o n t a l section o f t h e r u p t u r e d P C L n o h y p e r e c h o i c l i g a m e n t o u s i m a g e was s e e n in t h e n o r m a l P C L .

Results

Normal A CL
U l t r a s o n o g r a m of t h e sagittal s e c t i o n of the m i d d l e half o f A C L was i m a g e d as a straight h y p e r e c h o i c b a n d as

Discussion
A r t h r o g r a p h y has b e e n u s e d for t h e diagnosis of A C L a n d P C L r u p t u r e s . B u t the i n j e c t i o n o f c o n t r a s t m e d i u m

Table 1. Details of the patients with rupture of anterior cruciate ligament

Pa- Sex and age tient no. 1 2 3 4 5 6 7 8 9 Female, 16 Female, 16 Female, 26 Male, 30 Male, 33 Male, 16 Female, 16 Male, 16 Male, 37

Causation of injury Sport injury Traffic accident Sport injury Sport iniury Sport injury Sport injury Sport injury Sport injury Traffic accident

Duration of Lach- Ultra- AtFindings at symptoms mann's sound thro- operation test scopy 16 weeks 4 weeks 3 weeks 10 years 7 years 3 weeks 14 weeks 12 weeks 6 years Yes Yes Yes Yes Yes Yes Yes Yes Yes CR CR CR CR CR IR IR IR IR CR CR CR CR CR IR IR IR IR CR CR CR CR CR No operation IR No operation No operation

CR, complete rupture; IR, incomplete rupture

Table 2. Details of the patients with rupture of posterior cruciate ligament

Pa- Sex and age tient no. 1 2 3 4 5 Male, 16 Female, 16 Male, 17 Male, 24 Male, 37

Causation of injury

Duration of Pos- Ultra- ArFindings at symptoms terior sonog- thro- operation drawer raphy scopy sign i week 4 weeks 10 weeks 5 weeks 6 years Yes Yes Yes Yes Yes CR CR CR CR CR ND ND CR CR CR CR CR CR No operation CR

Traffic accident Traffic accident Traffic accident Falling Traffic accident

ND, not done

202

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S. Suzuki et al.: Ultrasound diagnosis of cruciate ligaments

203 The differentiation of complete from incomplete rupture is often difficult by arthroscopy [2, 3], for the old ruptured A C L is sometimes covered by fibrous tissures. Ultrasound, however, makes it possible to diagnose incomplete rupture by comparing the horizontal section area of the damaged ligament with that of the normal one. When the A C L is examined in the saggital section, it is very important that the probe is placed parallel to the direction of the ligament by using a sonoconductor as noted by Laine et al. [4]. Otherwise, a clear image of the A C L cannot be obtained. The horizontal section of A C L can readily demonstrate the hyperechoic image of the ACL, which consists of several bundles. The diagnosis of PCL rupture was much easier. When a posterior approach is used, the image is very clear, as the probe can be placed parallel to the direction of the ligament without the sonoconductor. In addition, there are no bones preventing the ultrasound beam from reaching the ligament. Therefore, ultrasound can demonstrate the entire length of PCL. Arthroscopy for PCL examination is not so easy, for the conventional lateral infrapatellar approach does not usually allow demonstration of the PCL and then another approach must be added. Examination by ultrasound is an effective and safe procedure for the diagnosis of knee ligament injury.

Fig.7. Sagittal section of ruptured posterior cruciate ligament

(arrow)

into the joint presents risks for infection, and it is sometimes difficult to demonstrate a clear image of the ligament. Although arthroscopy is now widely used for the diagnosis of A C L rupture, anesthesia and strict aseptic procedures are necessary for the examination. Therefore, a safer examination method has been looked for. Diagnostic examination of the cruciate ligaments by magnetic resonance imaging (MRI) can be a good method in the case of the A C L [1, 5], but it is very costly and the patients have to invest quite some time. On the other hand, examination by ultrasound demands neither anesthesia nor aseptic procedures, Exposure to ultrasound is harmless, and patients feel no pain after the procedure. Therefore, it can be done as often as necessary. The examination does not cost as much as MRI and it can be done more quickly.

References 1. Glashow JL, Kats R, Schneider M, Scott WN (1989) Doubleblind assessment of the value of magnetic resonance imaging in the diagnosis of anterior cruciate and meniscal lesions. J Bone Joint Surg [Am] 71 : 113-119 2. Hirose H, Doi T, Nishiue S, Henmi S (1987) Arthroscopic findings and derect visual findings during arthrotomy for injury of the anterior cruciate ligament. Arthroscopy (Jpn) 12 : 41-43 3. Ihara H, Tanabe K, Murao T (1985) Arthroscopy in the diagnosis of cruciate ligament injuries of the knee. Arthroscopy (Jpn) 10 : 31-36 4. Laine HR, Harjula A, Peltokallio P (1987) Ultrasound in the evaluation of the knee and patellar regions. J Ultrasound Med 6 : 33-36 5. Polly DW, Callaghan JJ, Sikes RA, McCabe JM, McMahon K, Savory CG (1988) The accuracy of selective magnetic resonance imaging compared with the findings of arthroscopy of the knee. J Bone Joint Surg [Am] 70 : 192-198

Fig.3a, b. Sagittal section of normal anterior crucate ligament. A, Anterior cruciate ligament; F, femur; T, tibia Fig. 4a, b. Horizontal section of normal anterior cruciate ligament Fig. 5a, b. Sagittal section of normal posterior cruciate ligament. P, Posterior cruciate ligament Fig. 6a, b. Horizontal section of normal posterior cruciate ligament. me, Medial condyle; la, lateral condyle