Clinically Reliable Knee Flexion Angle Measured On Stress Radiography For Quantifying Posterior Instability In Posterior Cruciate Ligament Injury

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 a KFA of 90 degrees, 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 using a Telos device with a 150-N posterior load. A total of 120 knees and 644 stress radiographs were included. 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 degrees to 106.7 degrees. Among the 644 radiographs, 155 (24.1%) showed KFAs between 85 degrees and 95 degrees, and 287 (44.6%) showed KFAs between 80 degrees and 85 degrees. 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 degrees to 92 degrees 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 degrees to 92 degrees in noninjured knees.