2025 ISAKOS Congress in Munich, Germany

2025 ISAKOS Biennial Congress Paper


Deep Dive on Sulcus Angle: Optimal Axial MRI Slice Selection and Cutoff Values

Mauricio Drummond, Jr., MD, Astoria, NY UNITED STATES
Jason Brenner, MS, Bronx, NY UNITED STATES
Steven Henick, MD, Bronx, NY UNITED STATES
Leila M. Alvandi, PhD, Bronx UNITED STATES
Edina Gjonbalaj, BS, Bronx UNITED STATES
Benjamin Levy UNITED STATES
Jacob Schulz, Bronx, NY UNITED STATES
Eric D. Fornari, MD, Mount Kisco, NY UNITED STATES

Montefiore Einstein, Bronx, NY, UNITED STATES

FDA Status Not Applicable

Summary

A cartilaginous SA greater than 162° measured at most proximal axial MRI cut is highly associated (OR=33.65) with recurrent patellar dislocation.

Abstract

Objectives:: The sulcus angle (SA) is defined as the angle formed by the lateral and medial trochlear facets and is an important measure used to evaluate trochlear dysplasia (TD). The mean cartilaginous SA in patients with patellofemoral instability (PI) was found to be 156.24° (95% CI: 153.71 – 158.77) and in controls to be 141.83° (95% CI: 139.90 – 143.76) based on MRI analysis. However, these studies assess TD at just one slice of the trochlear groove (TG) even though MRIs capture several relevant axial images. The purpose of this study is twofold: first, to establish the optimal cutoff value of the sulcus angle measured along the cartilaginous surface of the TG at four consecutive axial images and second, to identify the optimal axial image selection.

Methods

We retrospectively reviewed patients ages 9-25 at a tertiary care center (2012-2023) with PI to isolate those with recurrent patella dislocations (RPDs); age and sex-matched controls were identified from an internal database of patients with anterior cruciate ligament (ACL) injuries. Patients with prior surgery in the affected knee and those with substandard MRI studies were excluded. The proximal TG was defined as the most proximal axial image in which the cartilaginous portions of the medial and lateral trochlea are visible. Cartilaginous SA was recorded on MRI studies at four consecutive axial images for all participants (SA1 – most proximal, SA2, SA3, SA4 – most distal). We conducted the following tests: independent samples t-tests, Pearson correlations, receiver operating characteristics curve to determine area under the curve (AUC) and odds ratios (OR) using the 25th percentile of the recurrent group as the cutoff.

Results

In total, 206 knees were included in our measurements (106 Recurrent PI, average age = 15.29 ± 2.45; 100 ACL controls, average age = 15.60 ± 1.41; p=.277). Overall average SA is 159.6° RPDs and 147.3° in controls. SA1 (167.5 vs 152.4, p<0.01, r 0.88), SA2 (162.5 vs 148.4, p<0.01, r 0.91), SA3 (156.6 vs 145.8, p<0.01, r 0.85), SA4 (151.7 vs 142.4, p<0.01, r 80). Cut off value SA1 (>162, OR 33.65, 95% CI 14.46-78.28), SA2 (>155, OR 25.06, 95% CI 11.77-53.33), SA3 (>151, OR 13.33, 95% CI 6.81-26.09), SA4 (>146, OR 5.52, 95% CI 3.01-10.10)

Conclusion

The cartilaginous SA is greater in RPDs than in controls at all levels of the trochlear groove. The “cutoff” for pathologic SA needs to be adjusted based on the level at which the trochlea is being assessed on MRI. Cartilaginous SA is more strongly associated with PI status at the proximal-most TG than at the distal trochlear groove. A cartilaginous SA greater than 162° measured at most proximal axial MRI cut is highly associated (OR=33.65) with recurrent patellar dislocation. Odds ratio calculations suggest that TD in RPDs is more pathological in the proximal TG and more normal distally.