Evaluation of the Tibial Tubercle to Posterior Cruciate Ligament Distance in a Pediatric Patient Population

Background: Evaluation of distal extensor mechanism alignment continues to evolve in children with patella instability. Prior studies support the use of the tibial tubercle to trochlear groove (TT-TG) distance but limitations exist for this measurement including: changes in the TT-TG distance with knee flexion, difficulty with finding the deepest part of a dysplastic trochlea, and limitations regarding identification of the site of the anatomic abnormality. The tibial tubercle-posterior cruciate ligament (TT-PCL) distance has been introduced as an alternative measure to address the shortcomings in the TT-TG distance by quantifying the position of the TT independent of the trochlea and with respect to the tibia only. The objectives of this study were to (1) confirm that TT-PCL measurements in the pediatric population are reliable and reproducible; (2) determine whether normal TT-PCL distance changes with age; and (3) compare TT-PCL distances in patients with and without patellar instability to assess its utility in the workup of pediatric patellar instability. Methods: All knee magnetic resonance imaging performed for patients from birth to 15.9 years of age at our institution between December 2004 and February 2012 were retrospectively collected (total 566). Eighty-two patients had patellar instability and 484 patients did not have patellar instability. Two magnetic resonance imaging reviewers measured TT-PCL distance on T2-weighted axial images in a blinded manner. Intraobserver and interobserver agreement was measured. Correlation between TT-PCL distance and age as well as group differences between mean TT-PCL distances was evaluated. Results: Intraobserver and interobserver agreement was excellent (0.93) and very good (0.80), respectively. The mean TT-PCL distance was 20.1mm with a range of 5.8 to 32.1 mm. The mean age was 12.6 years with a range of 0.8 to 15.9 years. The average TT-PCL distance was 21mm for the instability group and 19.9mm for the control group. TT-PCL distance increased significantly as subject age increased; however, there was no significant measurement difference shown between the patellar instability group and the control group. Conclusions: TT-PCL distance increased with age in the pediatric population but did not correlate with recurrent patella instability in this pediatric cohort.