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      Double Posterior Cruciate Ligament Sign on Magnetic Resonance Imaging: Imaging Variants, Mimics, and Clinical Implications

      case-report

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          Abstract

          Introduction:

          Double posterior cruciate ligament (PCL) sign is a sign on magnetic resonance imaging (MRI) which is suggestive of a bucket- handle tear (BHT) of the meniscus. We undertook this study to assess the presence of a double PCL sign and its correlation with arthroscopic findings. We also discussed the various mimics and variants of the double PCL sign.

          Case Report:

          All the patients with a double PCL sign on the MRI and who underwent knee arthroscopy between January 2012 and December 2016 (total of 5 cases, 4 males and one female) were included in the study. A correlation between the imaging findings and the MRI findings was done. All these young patients were aged between 22 and 41 years. Two patients underwent arthroscopic partial meniscectomy, and three patients underwent arthroscopic meniscal repair using all inside technique.

          Conclusion:

          It is necessary for the sports physician to understand and recognize this important and subtle sign on MRI which is suggestive of a BHT of the meniscus. It is also important to identify the mimics of this sign and its variants for better management planning and patient prognostication.

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          Most cited references11

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          Bucket-handle meniscal tears of the knee: sensitivity and specificity of MRI signs.

          C. Helms, T A Dorsay (2003)
          To determine the sensitivity and specificity of reported MRI signs in the evaluation of bucket-handle tears of the knee. A retrospective analysis of 71 knee MR examinations that were read as displaying evidence of a bucket-handle or "bucket-handle type" tear was performed. We evaluated for the presence or absence of the absent bow tie sign, the coronal truncation sign, the double posterior cruciate ligament (PCL) sign, the anterior flipped fragment sign, and a fragment displaced into the intercondylar notch. Sensitivity and specificity were calculated relative to the gold standard of arthroscopy. Forty-three of 71 cases were surgically proven as bucket-handle tears. The absent bow tie sign demonstrated a sensitivity of 88.4%. The presence of at least one of the displaced fragment signs had a sensitivity of 90.7%. A finding of both the absent bow tie sign and one of the displaced fragment signs demonstrated a specificity of 85.7%. The double PCL sign demonstrated a specificity of 100%. The anterior flipped meniscus sign had a specificity of 89.7%. Bucket-handle tears of the menisci, reported in about 10% of most large series, have been described by several signs with MRI. This report gives the sensitivity and specificity of MRI for bucket-handle tears using each of these signs independently and in combination. MRI is shown to be very accurate for diagnosing bucket-handle tears when two or more of these signs coexist.
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            The quadruple cruciate sign of simultaneous bicompartmental medial and lateral bucket-handle meniscal tears.

            A Bugnone, Venktesh R Ramnath, S. Davis … (2005)
            We report the second known case of bicompartmental bucket-handle tears of the medial and lateral menisci and the first documented case of the bucket-handle tears occurring simultaneously following trauma, which occurred after a motorcycle accident. Both bucket-handle fragments were displaced into the intercondylar notch. An anterior cruciate ligament tear was also present. Coronal images demonstrated four structures in the intercondylar notch: the anterior and posterior cruciate ligaments and the medial and lateral bucket-handle meniscal fragments.
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              Sagittal MR images of the knee: a low-signal band parallel to the posterior cruciate ligament caused by a displaced bucket-handle tear.

              K Weiss, H T Morehouse, I Levy (1991)
              A low-signal band parallel and anterior to the posterior cruciate ligament has been noted on sagittal MR images of the knee in some patients with other evidence for medial meniscal tears. It was hypothesized that this low-signal band represented the mesially displaced fragment of a bucket-handle tear. To verify this, we retrospectively reviewed MR and arthroscopic findings in 54 consecutive patients. Arthroscopy showed a bucket-handle tear of the medial meniscus in seven patients and was considered diagnostic. Sagittal MR images were reviewed without knowledge of the arthroscopic results. The presence of a curvilinear low-signal band above the tibial cortex anterior, inferior, and parallel to the posterior cruciate ligament was identified on MR images in all seven of the patients in whom the presence of a bucket-handle medial meniscal tear was confirmed by arthroscopy. Our findings suggest that a low-signal band anterior and parallel to the posterior cruciate ligament on sagittal MR images of the knee is caused by a mesially displaced bucket-handle tear of the medial meniscus.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Orthop Case Rep
                Journal ID (iso-abbrev): J Orthop Case Rep
                Title: Journal of Orthopaedic Case Reports
                Publisher: Indian Orthopaedic Research Group (India )
                ISSN (Print): 2250-0685
                ISSN (Electronic): 2321-3817
                Publication date (Print): Nov-Dec 2017
                Volume: 7
                Issue: 6
                Pages: 76-79
                Affiliations
                [1 ]Department of Orthopaedics and Joint Replacement, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, India
                [2 ]Department of Radiodiagnosis, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, India
                Author notes
                Address of Correspondence: Dr. Vipul Vijay, Department of Orthopaedics, Indraprastha Apollo Hospital, New Delhi - 110076, India. E-mail: dr_vipulvijay@ 123456yahoo.com
                Article
                Publisher ID: JOCR-7-76
                DOI: 10.13107/jocr.2250-0685.958
                PMC ID: 5868891
                SO-VID: d4032cd8-efd0-45e8-bc28-89d1788c4903
                Copyright © Copyright: © Indian Orthopaedic Research Group
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Categories
                Subject: Case Report

                Keywords: meniscus,cruciate ligaments,knee,bucket-handle tear,magnetic resonance imaging,meniscectomy,repair
                Data availability:
                Keywords: meniscus, cruciate ligaments, knee, bucket-handle tear, magnetic resonance imaging, meniscectomy, repair

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