quantification of ant laxity of the knee stress xr · 2017. 1. 12. · and 487 acl deficient knees...
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Stress-radiography of the kneeAnterior and posterior translation
at 20° of flexion in 563 normal knees
and 487 ACL deficient knees
StressStress--radiographyradiography of the of the kneekneeAnteriorAnterior andand posteriorposterior translation translation
atat 2020°° of flexion of flexion in 563 normal in 563 normal kneesknees
andand 487 ACL 487 ACL deficientdeficient kneesknees
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AimsAims of the of the studystudy
•• The The measurementsmeasurements of of anterioranterior andand posteriorposterior laxitylaxity–– in normal in normal kneesknees–– andand in ACL in ACL deficientdeficient kneesknees
•• DiagnosisDiagnosis valuevalue
•• GradingGrading the the kneeknee play in play in orderorder to to choosechoose adaptatedadaptatedsurgerysurgery
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Flexion : 90°• Nyga : 1970• Kennedy, Fowler : 1971• Lerat : 1971• Jacobsen : 1976
AnteriorAnterior stressstress--radiographyradiography
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TORG introduced the "LACHMAN test"
in 1976
Test practised since 1963 byTRILLAT in Lyon-France
AnteriorAnterior stressstress--radiographyradiography
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AnteriorAnterior stressstress--radiographyradiography
20° of flexion• Lerat (manually) : 1979• Lerat (apparatus) : 1982• Stäubli, Jakob : 1982• Hooper : 1986• Iversen : 1988
apparatus
l
apparatus
Manualy
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AnteriorAnterior andand posteriorposterior stressstress--radiographyradiography
The same apparatus is used for both anterior and posterior tests
•• 2020°° of flexionof flexion•• FixedFixed loadload (9 kg)(9 kg)•• Free translationFree translation•• Free rotationFree rotation•• ComfortableComfortable for the for the
patientspatients
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AnteriorAnterior translation of the tibiatranslation of the tibia
•• PosteriorPosterior tibial cortextibial cortexas as referencereference lineline
•• ParallelsParallels tangent to the tangent to the posteriorposterior aspect of the aspect of the condylescondyles
•• Distance Distance betweenbetween thesethesetangent tangent lineslines andand the the tibial tibial compartmentscompartments
ATMC: ATMC: AnteriorAnterior Translation of Translation of MedialMedial CompartmentCompartment
ATLC : ATLC : AnteriorAnterior Translation of Translation of LateralLateral CompartmentCompartment
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LandmarksLandmarks
Lateral condyle : anterior notch and posterior angle
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ATMC
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ATLC
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ATMCATMC andand ATLCATLC
AnteriorAnterior radiologicalradiological drawerdrawer
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PTMCPTMC = = PosteriorPosterior Translation of Translation of MedialMedial CompartmentCompartment
PTLC = PTLC = PosteriorPosterior Translation of Translation of LateralLateral CompartmentCompartment
PosteriorPosterior translation of the tibiatranslation of the tibia
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• 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
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• 2100 X-ray films• 4200 measurements
• One observer (JL L)
methodsmethods
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Interobserver intraclass correlation3 observers
50 patients measured(ruptured ACL - normal knee)
Intraobserver intraclass correlation1 observer measured 50 patients twice
MethodsMethods
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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 correlationfor ATMC and ATLC
All values include 95 % confidence intervals
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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
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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
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• 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
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•• specificityspecificity = 90 %= 90 %•• sensitivitysensitivity = 87 %= 87 %•• predictpredict positposit. val = 89 %. val = 89 %•• predictpredict negatnegat. val = 88 %. val = 88 %
•• 87%87%•• 79 %79 %•• 85 %85 %•• 82 %82 %
ATMCATMC ATLCATLC
Cut point : 6 mm Cut point : 11.5 mm
DiagnosisDiagnosis of ACL rupture of ACL rupture The ATMC The ATMC isis the the mostmost reliablereliable
.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
Sens
itivi
ty
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Medial
Compartment
PTMC +ATMC
4.2 ± 2.7 mm
PhysiologicalPhysiological antant--postpost laxitylaxity
LateralCompartiment
PTLC +ATLC
12.2 ± 4.5 mm
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Medial
Compartment
PTMC +ATMC
12.1 ± 4.5 mm
PathologicalPathological antant--postpost laxitylaxity
LateralCompartiment
PTLC +ATLC
19.4 ± 5.5 mm
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Considering differential laxity
PathologicalPathological ATMCATMC andand ATLC ATLC Normal Normal contralateralcontralateral kneeknee
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ACL ACL deficientdeficient kneesknees : : differentialdifferential antant. translation. 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
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• Translation of the lateral sidecan be predominent
internal tibial rotation
AnteriorAnterior laxitieslaxities classificationclassification
• Translation of the medial sidecan be predominent
external tibial rotation
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< 5mm
5-8mm
8-11mm
>11mm
05
1015202530
< 5mm
5-8mm
8-11mm
>11mm
AnteriorAnterior laxitieslaxities classificationclassification
ATMCATMC
Casesnumber
%
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AnteriorAnterior laxitieslaxities : grade 1: grade 1
5
8
11
Diff. Laxity mm
zero position line
15
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AnteriorAnterior laxitieslaxities : grade 1: grade 1
1285
8
11
Diff. Laxity
zero position line
15ATMC
knees
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AnteriorAnterior laxitieslaxities : grade 1: grade 1
128 595
8
11
Diff. Laxity
zero position line
15ATMC ATLC
1 D
1 C
1 B
1 A
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AnteriorAnterior laxitieslaxities : grade 1: grade 1
128
36
595
8
11
Diff. Laxity
zero position line
15ATMC ATLC
1 D
1 C
1 B
1 A
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AnteriorAnterior laxitieslaxities : grade 1: grade 1
128
36
22
595
8
11
Diff. Laxity
zero position line
15ATMC ATLC
1 D
1 C
1 B
1 A
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AnteriorAnterior laxitieslaxities : grade 1: grade 1
128
36
22
11
595
8
11
Diff. Laxity
zero position line
15ATMC ATLC
1 D
1 C
1 B
1 A
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116 25
25
18
485
8
11
Diff. Laxity
Zero position line
15
AnteriorAnterior laxitylaxity : grade 2: grade 2
ATMC ATLC
2 D
2 C
2 B
2 A
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AnteriorAnterior laxitylaxity : grade 3: 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
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AnteriorAnterior laxitylaxity : grade 4 : grade 4
91
19
115
8
11
Diff. Laxity
zero position line
15
4 D
4 C
4 B
4 A
ATLCATMC
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AnteriorAnterior laxitylaxity : grade 4 : grade 4
91
19
37
24
115
8
11
Diff. Laxity
zero position line
15
4 D
4 C
4 B
4 A
ATLCATMC
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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
AnteriorAnterior laxitieslaxities classificationclassification
Grade 4
Grade 3
Grade 2
Grade 1
ATMC (first number) : 4 grades
ATLC (A, B, C or D) : 4 grades
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2.5 4.3 8.3 5. 48 4. 2 5.5 6.5
10.8 5.6 5.6 413.2 8 4 2
Grade 4
Grade 3
Grade 2
Grade 1
Number of cases for all categories ( % )
n = 487
AnteriorAnterior laxitieslaxities classificationclassification
A B C D
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Prospective Prospective surgerysurgery
2 A 2 B 2 C 2 D1 A 1 B 1 C 1 D
isolated ACL ACL + extra-articularlateral reconstruction
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Prospective Prospective surgerysurgery
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 articularlateral reconstruction
19 %
17 %38 %
26 %
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Precice and objective measurement of preop and post-op laxity
PreoperativePreoperative ATMCATMC andand ATLC ATLC Post Post opop 10 10 yearsyears
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"Mac InJones » procedure
QuadricipitalQuadricipital tendon tendon isis stretchedstretched fromfrom the condyle the condyle to the Gerdyto the Gerdy’’s tubercule s tubercule withwith solidsolid suturessutures
ACL reconstruction with patellar tendon
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Evolution of Evolution of radiologicalradiological laxitylaxity afterafter surgerysurgery
0123456789
preop 6 m 1 year > 10 y
ATMCTACE
Gain for ATMC : 62 % Gain for ATMC : 62 % Gain for ATLC : 77 %Gain for ATLC : 77 %
DifferentialDifferential leftleft/right /right laxitylaxity
ACL reconstruction + lateral plasty : 100 cases
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In the same way, a prospective study is started to evaluate postero-medial reconstruction
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• Conclusive diagnosis for ACL rupture
• Better comprehension of laxity physiopathology
• Laxities classification
• Judicious surgical treatment adaptated to the lesions
ConclusionsConclusions
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