Stress-radiography of the knee Anterior and posterior translation at 20° of flexion in 563 normal...
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Stress-radiography of the knee Stress-radiography of the knee Anterior and posterior translation Anterior and posterior translation
at 20° of flexion at 20° of flexion in 563 normal kneesin 563 normal knees
and 487 ACL deficient knees and 487 ACL deficient knees
Stress-radiography of the knee Stress-radiography of the knee Anterior and posterior translation Anterior and posterior translation
at 20° of flexion at 20° of flexion in 563 normal kneesin 563 normal knees
and 487 ACL deficient knees and 487 ACL deficient knees
JL. LERAT, JL. BESSE, F. CHOTEL, F. CLADIERE, B. MOYEN JL. LERAT, JL. BESSE, F. CHOTEL, F. CLADIERE, B. MOYEN
Department of Orthopaedic Surgery and Sports MedicineDepartment of Orthopaedic Surgery and Sports Medicine
Lyon – FranceLyon – France
ESSKA, Nice, 5-1998
EFORT, Bruxelles 3-8 June 1999
Aims of the studyAims of the study
• The measurements of anterior and posterior laxity The measurements of anterior and posterior laxity – in normal kneesin normal knees– and in ACL deficient kneesand in ACL deficient knees
• Diagnosis valueDiagnosis value
• Grading the knee play in order to choose adaptated Grading the knee play in order to choose adaptated
surgerysurgery
Flexion : 90°• Nyga : 1970• Kennedy, Fowler : 1971• Lerat : 1971• Jacobsen : 1976
Anterior stress-radiographyAnterior stress-radiography
TORG introduced the "LACHMAN test"
in 1976
Test practised since 1963 byTRILLAT in Lyon-France
Anterior stress-radiographyAnterior stress-radiography
Anterior stress-radiographyAnterior stress-radiography
20° of flexion• Lerat (manually) : 1979• Lerat (apparatus) : 1982• Stäubli, Jakob : 1982• Hooper : 1986• Iversen : 1988
apparatus
l
apparatus
Manualy
Anterior and posterior stress-radiographyAnterior and posterior stress-radiography
The same apparatus is used for both anterior and posterior tests
• 20° of flexion20° of flexion• Fixed load (9 kg)Fixed load (9 kg)• Free translationFree translation• Free rotationFree rotation• Comfortable for the Comfortable for the
patientspatients
Anterior translation of the tibiaAnterior translation of the tibia
• Posterior tibial cortexPosterior tibial cortex
as reference lineas reference line
• Parallels tangent to the Parallels tangent to the posterior aspect of the posterior aspect of the condylescondyles
• Distance between these Distance between these tangent lines and the tangent lines and the
tibial compartmentstibial compartments
ATMC: ATMC: Anterior Translation of Medial CompartmentAnterior Translation of Medial Compartment
ATLC : ATLC : Anterior Translation of Lateral CompartmentAnterior Translation of Lateral Compartment
LandmarksLandmarks
Lateral condyle : anterior notch and posterior angle
ATMC
ATLC
ATMCATMC and and ATLCATLC
Anterior radiological drawerAnterior radiological drawer
PTMCPTMC = = Posterior Translation of Medial CompartmentPosterior Translation of Medial Compartment
PTLC = PTLC = Posterior Translation of Lateral CompartmentPosterior Translation of Lateral Compartment
Posterior translation of the tibiaPosterior translation of the tibia
• 1050 knees measured• 487 ACL insufficient knees• 487 contra-lateral normal knees• 76 normal subjects
• age : 27.5 ± 9 years (16-50)
• 70.5 % males, 29.5 % females
• no previous surgery• no meniscus bucket-handle
MaterielMateriel
• 2100 X-ray films• 4200 measurements
• One observer (JL L)
methodsmethods
Interobserver intraclass correlation3 observers
50 patients measured(ruptured ACL - normal knee)
Intraobserver intraclass correlation1 observer measured 50 patients twice
MethodsMethods
Normal Deficient ACL
ATMC 0.91 (0.85 - 0.95) 0.95 (0.90 - 0.98)
0.97 (0.95 - 0.98) 0.98 (0.94 - 0.98)
ATLC 0.92 (0.85 - 0.95) 0.92 (0.85 - 0.95)
0.93 (0.89 - 0.96) 0.95 (0.92 - 0.97)
Intra and interobserver intraclass correlation for ATMC and ATLC
All values include 95 % confidence intervals
Right-left difference38 normal subjects
Ant Transl Medial Comp : 0.5 ± 0.4 mm
Ant Transl Lateral Comp : 1.2 ± 0.4 mm
Post Transl Medial Comp : 1.1 ± 0.7 mm
Post Transl Lateral Comp : 1.5 ± 1.2 mm
RESULTSRESULTS
ATMC = 10.4 ± 4.3
ATLC = 18.5 ± 5.1
PTMC = 2.7 ± 2.9
PTLC = 1.1 ± 4.1
ATMC = 2.1 ± 2.6
ATLC = 10.5 ± 3.5
PTMC = 2.1 ± 2.9
PTLC = 1.7 ± 4.1
563 normal knees 478 ACL deficient knees
No difference between males and females
RESULTSRESULTS
• No difference for posterior translation (ACL ruptured or not )
• Posterior position is different from the radiological "zero position"
• It is the "starting position" for clinical tests and for arthrometric measurements
RESULTSRESULTS
PTMC = 2.1 ± 2.9
PTLC = 1.7 ± 4.1
• specificity = 90 %specificity = 90 %• sensitivity = 87 %sensitivity = 87 %• predict posit. val = 89 %predict posit. val = 89 %• predict negat. val = 88 %predict negat. val = 88 %
• 87%87%• 79 %79 %• 85 %85 %• 82 %82 %
ATMCATMC ATLCATLC
Cut point : 6 mm Cut point : 11.5 mm
Diagnosis of ACL rupture Diagnosis of ACL rupture The ATMC is the most reliable The ATMC is the most reliable
.0 .1 .2 .3 .4 .5 .6 .7 .8 .9 1.0
.0
.1
.2
.3
.4
.5
.6
.7
.8
.9
1.0
1-specificity
Sensitivity
Medial
Compartment
PTMC +ATMC
4.2 ± 2.7 mm
Physiological ant-post laxity Physiological ant-post laxity
Lateral Compartiment
PTLC +ATLC
12.2 ± 4.5 mm
Medial
Compartment
PTMC +ATMC 12.1 ± 4.5 mm
Pathological ant-post laxity Pathological ant-post laxity
Lateral Compartiment
PTLC +ATLC 19.4 ± 5.5 mm
Considering differential laxity
Pathological Pathological ATMCATMC and and ATLC ATLC Normal contralateral kneeNormal contralateral knee
ACL deficient knees : differential ant. translationACL deficient knees : differential ant. translation
ATLC7.5 ± 4.6 mm
ATMC
8.1 ± 4.2 mm
0
10
20
30
40
50
60
70
80
-5 0 5 10 15 20 25
Differential ATLC
0
10
20
30
40
50
60
70
80
-5 0 5 10 15 20
Differential ATMC
• Translation of the lateral side can be predominent
internal tibial rotation
Anterior laxities classificationAnterior laxities classification
• Translation of the medial side can be predominent
external tibial rotation
< 5mm
5-8mm
8-11mm
>11mm
05
1015202530
< 5mm
5-8mm
8-11mm
>11mm
Anterior laxities classificationAnterior laxities classification
ATMCATMC
Casesnumber
%
Anterior laxities : grade 1Anterior laxities : grade 1
5
8
11
Diff. Laxity mm
zero position line
15
Anterior laxities : grade 1Anterior laxities : grade 1
1285
8
11
Diff. Laxity
zero position line
15ATMC
knees
Anterior laxities : grade 1Anterior laxities : grade 1
128 595
8
11
Diff. Laxity
zero position line
15ATMC ATLC
1 D
1 C
1 B
1 A
Anterior laxities : grade 1Anterior laxities : grade 1
128
36
595
8
11
Diff. Laxity
zero position line
15ATMC ATLC
1 D
1 C
1 B
1 A
Anterior laxities : grade 1Anterior laxities : grade 1
128
36
22
595
8
11
Diff. Laxity
zero position line
15ATMC ATLC
1 D
1 C
1 B
1 A
Anterior laxities : grade 1Anterior laxities : grade 1
128
36
22
11
595
8
11
Diff. Laxity
zero position line
15ATMC ATLC
1 D
1 C
1 B
1 A
116 25
25
18
48
5
8
11
Diff. Laxity
Zero position line
15
Anterior laxity : grade 2Anterior laxity : grade 2
ATMC ATLC
2 D
2 C
2 B
2 A
Anterior laxity : grade 3Anterior laxity : grade 3
109
19
26
29
355
8
11
Diff. Laxity
Zero position line
15
3 D
3 C
3 B
3 A
ATMC ATLC
Anterior laxity : grade 4 Anterior laxity : grade 4
91
19
115
8
11
Diff. Laxity
zero position line
15
4 D
4 C
4 B
4 A
ATLCATMC
Anterior laxity : grade 4 Anterior laxity : grade 4
91
19
37
24
115
8
11
Diff. Laxity
zero position line
15
4 D
4 C
4 B
4 A
ATLCATMC
4 - A 4 - B 4 - C 4 - D3 - A 3 - B 3 - C 3 - D2 - A 2 - B 2 - C 2 - D1 - A 1 - B 1 - C 1 - D
Anterior laxities classificationAnterior laxities classification
Grade 4
Grade 3
Grade 2
Grade 1
ATMC (first number) : 4 grades
ATLC (A, B, C or D) : 4 grades
2.5 4.3 8.3 5. 4
8 4. 2 5.5 6.5
10.8 5.6 5.6 4
13.2 8 4 2
Grade 4
Grade 3
Grade 2
Grade 1
Number of cases for all categories ( % )
n = 487
Anterior laxities classificationAnterior laxities classification
A B C D
Prospective surgeryProspective surgery
2 A 2 B 2 C 2 D1 A 1 B 1 C 1 D
isolated ACL ACL + extra-articular lateral reconstruction
Prospective surgeryProspective surgery
4 A 4 B 4 C 4 D3 A 3 B 3 C 3 D2 A 2 B 2 C 2 D1 A 1 B 1 C 1 D
isolated ACL
ACL + medial + lateralACL + medial
ACL + extra articular lateral reconstruction
19 %
17 %38 %
26 %
Precice and objective measurement of preop and post-op laxity
Preoperative Preoperative ATMCATMC and and ATLC ATLC Post op 10 yearsPost op 10 years
"Mac InJones » procedure
Quadricipital tendon is stretched from the condyle Quadricipital tendon is stretched from the condyle to the Gerdy’s tubercule with solid suturesto the Gerdy’s tubercule with solid sutures
ACL reconstruction with patellar tendon
Evolution of radiological laxity after surgeryEvolution of radiological laxity after surgery
0
1
2
3
4
5
6
7
8
9
preop 6 m 1 year > 10 y
ATMCTACE
Gain for ATMC : 62 % Gain for ATMC : 62 % Gain for ATLC : 77 %Gain for ATLC : 77 %
Differential left/right laxityDifferential left/right laxity
ACL reconstruction + lateral plasty : 100 cases
In the same way, a prospective study is started to evaluate postero-medial reconstruction
• Conclusive diagnosis for ACL rupture
• Better comprehension of laxity physiopathology
• Laxities classification
• Judicious surgical treatment adaptated to the lesions
ConclusionsConclusions
THANK YOU
Medial laxity : what i do ?
1/Tensioning of distal insertion
2/ Tensioning of proximal insertion
3/ Tension without detaching the distal and proximal insertionsusing semi tendinosus or quadricipital tendon
3/ Tension without detaching the distal and proximal insertions