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Stress Radiography of the Knee: Anterior and Posterior Translation at 20° Flexion

Study on anterior and posterior knee laxity; Diagnosis and surgery guidance based on knee play grading; Method comparison.

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Stress Radiography of the Knee: Anterior and Posterior Translation at 20° Flexion

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  1. Stress-radiography of the knee Anterior and posterior translation at 20° of flexion in 563 normal knees and 487 ACL deficient knees JL. LERAT, JL. BESSE, F. CHOTEL, F. CLADIERE, B. MOYEN Department of Orthopaedic Surgery and Sports Medicine Lyon – France ESSKA, Nice, 5-1998 EFORT, Bruxelles 3-8 June 1999

  2. Aims of the study • The measurements of anterior and posterior laxity • in normal knees • and in ACL deficient knees • Diagnosis value • Grading the knee play in order to choose adaptated surgery

  3. Anterior stress-radiography • Flexion : 90° • Nyga : 1970 • Kennedy, Fowler : 1971 • Lerat : 1971 • Jacobsen : 1976

  4. Anterior stress-radiography TORG introduced the "LACHMAN test" in 1976 Test practised since 1963 by TRILLAT in Lyon-France

  5. Anterior stress-radiography Manualy 20° of flexion • Lerat (manually) : 1979 • Lerat (apparatus) : 1982 • Stäubli, Jakob : 1982 • Hooper : 1986 • Iversen : 1988 l apparatus apparatus

  6. Anterior and posterior stress-radiography The same apparatus is used for both anterior and posterior tests • 20° of flexion • Fixed load (9 kg) • Free translation • Free rotation • Comfortable for the patients

  7. Anterior translation of the tibia • Posterior tibial cortex • as reference line • Parallels tangent to the posterior aspect of the condyles • Distance between these tangent lines and the • tibial compartments ATMC: Anterior Translation of Medial Compartment ATLC : Anterior Translation of Lateral Compartment

  8. Landmarks Lateral condyle :anterior notch and posterior angle

  9. ATMC

  10. ATLC

  11. Anterior radiological drawer ATMC and ATLC

  12. Posterior translation of the tibia PTMC = Posterior Translation of Medial Compartment PTLC = Posterior Translation of Lateral Compartment

  13. Materiel • 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

  14. methods • 2100 X-ray films • 4200 measurements • One observer (JL L)

  15. Interobserver intraclass correlation 3 observers 50 patients measured (ruptured ACL - normal knee) Intraobserver intraclass correlation 1 observer measured 50 patients twice Methods

  16. All values include 95 % confidence intervals Intra and interobserver intraclass correlation for ATMC and ATLC 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)

  17. RESULTS Right-left difference 38 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

  18. ATMC = 10.4 ± 4.3 ATLC = 18.5 ± 5.1 PTMC = 2.7 ± 2.9 PTLC = 1.1 ± 4.1 RESULTS 563 normal knees 478 ACL deficient knees • ATMC = 2.1 ± 2.6 • ATLC = 10.5 ± 3.5 • PTMC = 2.1 ± 2.9 • PTLC = 1.7 ± 4.1 No difference between males and females

  19. RESULTS • 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 • PTMC = 2.1 ± 2.9 • PTLC = 1.7 ± 4.1

  20. Diagnosis of ACL rupture The ATMC is the most reliable ATMC ATLC Cut point : 6 mm Cut point : 11.5 mm • specificity = 90 % • sensitivity = 87 % • predict posit. val = 89 % • predict negat. val = 88 % • 87% • 79 % • 85 % • 82 %

  21. Physiological ant-post laxity Medial Compartment PTMC +ATMC 4.2± 2.7 mm Lateral Compartiment PTLC +ATLC 12.2± 4.5 mm

  22. Pathological ant-post laxity Medial Compartment PTMC +ATMC 12.1± 4.5 mm Lateral Compartiment PTLC +ATLC 19.4± 5.5 mm

  23. Considering differential laxity Pathological ATMC and ATLC Normal contralateral knee

  24. ACL deficient knees : differential ant. translation ATMC 8.1± 4.2 mm ATLC 7.5± 4.6 mm

  25. Anterior laxities classification • Translation of the lateral side can be predominent internal tibial rotation • Translation of the medial side • can be predominent • external tibial rotation

  26. Anterior laxities classification Cases number % ATMC

  27. Anterior laxities : grade 1 Diff. Laxity mm 15 11 8 5 zero position line

  28. Anterior laxities : grade 1 Diff. Laxity ATMC 15 11 8 5 128 knees zero position line

  29. Anterior laxities : grade 1 Diff. Laxity ATMC ATLC 15 1 D 1 C 1 B 1 A 11 8 5 59 128 zero position line

  30. Anterior laxities : grade 1 Diff. Laxity ATMC ATLC 15 1 D 1 C 1 B 1 A 11 8 36 5 59 128 zero position line

  31. Anterior laxities : grade 1 Diff. Laxity ATMC ATLC 15 1 D 1 C 1 B 1 A 11 22 8 36 5 59 128 zero position line

  32. Anterior laxities : grade 1 Diff. Laxity ATMC ATLC 15 11 1 D 1 C 1 B 1 A 11 22 8 36 5 59 128 zero position line

  33. Anterior laxity : grade 2 Diff. Laxity ATLC ATMC 15 18 2 D 2 C 2 B 2 A 11 25 8 116 25 5 48 Zero position line

  34. Anterior laxity : grade 3 ATLC ATMC Diff. Laxity 15 29 3 D 3 C 3 B 3 A 11 109 26 8 19 5 35 Zero position line

  35. Anterior laxity : grade 4 ATMC ATLC Diff. Laxity 15 91 4 D 4 C 4 B 4 A 11 8 19 5 11 zero position line

  36. Anterior laxity : grade 4 ATMC ATLC Diff. Laxity 15 91 24 4 D 4 C 4 B 4 A 11 37 8 19 5 11 zero position line

  37. Anterior laxities classification Grade 4 Grade 3 Grade 2 Grade 1 ATMC (first number) : 4 grades ATLC (A, B, C or D) : 4 grades

  38. Anterior laxities classification Number of cases for all categories ( % ) Grade 4 Grade 3 Grade 2 Grade 1 n = 487 A B C D

  39. Prospective surgery ACL + extra-articular lateral reconstruction isolated ACL

  40. Prospective surgery ACL + medial ACL + medial + lateral 19 % 26 % 38 % 17 % ACL + extra articular lateral reconstruction isolated ACL

  41. Precice and objective measurement of preop and post-op laxity Preoperative ATMC and ATLC Post op 10 years

  42. "Mac InJones » procedure ACL reconstruction with patellar tendon Quadricipital tendon is stretched from the condyle to the Gerdy’s tubercule with solid sutures

  43. Evolution of radiological laxity after surgery ACL reconstruction + lateral plasty : 100 cases Differential left/right laxity Gain for ATMC : 62 % Gain for ATLC : 77 %

  44. In the same way, a prospective study is started to evaluate postero-medial reconstruction

  45. Conclusions • Conclusive diagnosis for ACL rupture • Better comprehension of laxity physiopathology • Laxities classification • Judicious surgical treatment adaptated to the lesions

  46. THANK YOU

  47. Medial laxity : what i do ?

  48. 1/Tensioning of distal insertion

  49. 2/ Tensioning of proximal insertion

  50. 3/ Tension without detaching the distal and proximal insertionsusing semi tendinosus or quadricipital tendon

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