Sensitivity and specificity of bell-hammer tear as an indirect sign of partial anterior cruciate ligament rupture on magnetic resonance imaging

Background:Cyclops syndrome is characterized by loss of terminal knee extension due to proliferative fibrous nodule formation in the intercondylar notch. This complication occurs in the early postoperative period after anterior cruciate ligament reconstruction (ACLR). The pathogenesis of Cyclops syndrome is not well understood.Hypothesis:Persistent hamstring contracture after ACLR is associated with an increased risk of subsequent Cyclops syndrome.Study Design:Case-control study; Level of evidence, 3.Methods:The files of 45 patients who underwent arthroscopic debridement of a Cyclops lesion after ACLR were analyzed. Recorded data included demographic information and technical details of surgery. Preoperative magnetic resonance images were also analyzed, and patients with femoral bone bruising were identified. Passive and active range of motion were recorded in all patients preoperatively and at 3 and 6 weeks after surgery to address the Cyclops lesion. Passive extension deficit was evaluated in comparison with the contralateral limb and classified as secondary to hamstring contracture when contracture was observed and palpated in the prone position and when the extension deficit was reversed after exercises performed to fatigue the hamstrings. A control group was selected using a random numbers table among our entire ACLR cohort. Statistical analysis was performed to analyze differences between the 2 groups.Results:There was no significant difference between the groups with regard to age at ACLR, sex distribution, time from injury to surgery (P > .05), proportion of professional athletes, presence of femoral bone bruise, or technical aspects of surgery. The overall extension deficit incidence was significantly higher in the Cyclops group at 3 weeks (Cyclops, 71%; control, 22%) (P < .001) and at 6 weeks (Cyclops, 60%; control, 7%) (P < .001). The extension deficit related to hamstring contracture was significantly higher in the Cyclops group at 3 weeks (Cyclops, 58%; control, 22%) (P < .001) and at 6 weeks (Cyclops, 29%; control, 2%) (P < .001).Conclusion:The Cyclops lesion is associated with a persistent hamstring contracture at 3 and 6 weeks after ACLR.

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“…The data from the preoperative magnetic resonance images were also analyzed, and patients with femoral bone bruising were identified. 9 …”

Section: Methodsmentioning

confidence: 99%

Hamstring Contracture After ACL Reconstruction Is Associated With an Increased Risk of Cyclops Syndrome

Pinto

Thaunat

Daggett

et al. 2017

Orthopaedic Journal of Sports Medicine

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“…In the Lelli study, the sensitivity of the examination method was evaluated according to the MRI diagnosis of the ACL tear (Lelli et al 2014 ). The sensitivity of MRI in the evaluation of ACL tear has been reported as 92–96 % (Steckel et al 2006 ; Lefevre et al 2014 ). Although arthroscopic evaluation is an invasive method, it is the gold standard for definitive diagnosis (Crawford et al 2007 ; Oei et al 2003 ).…”

Section: Discussionmentioning

confidence: 99%

The arthroscopical and radiological corelation of lever sign test for the diagnosis of anterior cruciate ligament rupture

et al. 2015

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The aim of the current study was to evaluate the sensitivity of the lever sign test and the widely used basic tests of the Lachman, anterior drawer and pivot shift tests, both under anaesthesia and without anaesthesia, according to the gold standard diagnostic arthroscopic results in patients undergoing anterior cruciate ligament reconstruction. The study included 117 patients, diagnosed with ACL tear which was definitively determined during an arthroscopic surgical procedure applied. Before anaesthesia and while under anaesthesia, the Lachman, anterior drawer, pivot shift and lever sign tests were applied to all patients. Evaluation was made of MR images for each patient and documented. The patients comprised 96 males and 21 females, witha mean age of 25.8 ± 5.9 years (range, 17–45 years). Total tear was determined in 82 cases, anteromedial (AM) bundle in 14, posterolateral (PL) bundle in 13 and elongation in 8. Pre-anaesthesia positivity was found in lever sign at 94.2 %, Lachman at 80.5 %, pivot shift at 62.3 % and anterior drawer at 60.1 %. These rates were determined after anaesthesia as lever sign 98.4 %, Lachman 88.7 %, pivot shift 88.3 % and anterior drawer 84.2 %. The lever sign test can be easily applied clinically and it seems to have higher sensitivity than the Lachman test which is the basis of classic information, it should be included in routine clinical practice. In the light of the results of this study, further studies are required to review the accepted view that the Lachmann test is the most reliable test.

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“…Occasionally, the distal stump of a torn ACL may flip anteriorly and may be responsible for locking, clinically mimicking a bucket-handle tear. This has been referred to as a preoperative cyclops lesion or a bell-hammer tear and has a higher incidence with partial tears with anteromedial bundle disruption (52). A number of secondary MR imaging signs of ACL injury have been described, such as anterior translation of the lateral tibial plateau in relation to the lateral femoral condyle, uncovering of the posterior horn of the lateral meniscus, and buckling of the PCL.…”

Section: State Of the Art: Athletic Injuries Of Knee Ligaments And Mementioning

confidence: 99%

“…Partial ACL tears account for 10%-36% of surgically treated patients (53) but this is likely a significant underestimate of the incidence of partial tears and there is debate as to the accuracy of clinical evaluation of partial ACL injuries. Tears of the anteromedial bundle are more common (52) and the anteromedial bundle is more prone to injury with the knee flexed, whereas the posterolateral bundle is at risk with hyperextension and internal rotation injuries (54). MR imaging has diminished accuracy in the diagnosis of partial ACL tears in comparison with complete tears…”

Section: State Of the Art: Athletic Injuries Of Knee Ligaments And Mementioning

confidence: 99%

Imaging of Athletic Injuries of Knee Ligaments and Menisci: Sports Imaging Series

Naraghi¹,

White²

2016

Radiology

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Acute knee injuries are a common source of morbidity in athletes and if overlooked may result in chronic functional impairment. Magnetic resonance (MR) imaging of the knee has become the most commonly performed musculoskeletal MR examination and is an indispensable tool in the appropriate management of the injured athlete. Meniscal and ligamentous tearing are the most frequent indications for surgical intervention in sports injuries and an understanding of the anatomy, biomechanics, mechanisms of injury, and patterns of injury are all critical to accurate diagnosis and appropriate management. These will be discussed in reference to meniscal tears and injuries of the cruciate ligaments as well as injuries of the posterolateral and posteromedial corners of the knee. (©) RSNA, 2016.

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Sensitivity and specificity of bell-hammer tear as an indirect sign of partial anterior cruciate ligament rupture on magnetic resonance imaging

Abstract: Diagnostic study, Level II.

Cited by 16 publications

References 23 publications

Hamstring Contracture After ACL Reconstruction Is Associated With an Increased Risk of Cyclops Syndrome

Hamstring Contracture After ACL Reconstruction Is Associated With an Increased Risk of Cyclops Syndrome

The arthroscopical and radiological corelation of lever sign test for the diagnosis of anterior cruciate ligament rupture

Imaging of Athletic Injuries of Knee Ligaments and Menisci: Sports Imaging Series

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