Transcript Cupule Spring - lerat orthopedie

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
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
Anterior stress-radiography
Flexion : 90°
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Nyga : 1970
Kennedy, Fowler : 1971
Lerat : 1971
Jacobsen : 1976
Anterior stress-radiography
TORG introduced the
"LACHMAN test"
in 1976
Test practised since 1963 by
TRILLAT in Lyon-France
Anterior stress-radiography
Manualy
20° of flexion
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l
Lerat (manually) : 1979
Lerat (apparatus) : 1982
Stäubli, Jakob : 1982
Hooper : 1986
Iversen : 1988
apparatus
apparatus
Anterior and posterior stress-radiography
The same apparatus is used for both anterior and posterior tests
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20° of flexion
Fixed load (9 kg)
Free translation
Free rotation
Comfortable for the
patients
Anterior translation of the tibia
ATMC:
ATLC :
Anterior Translation of Medial Compartment
Anterior Translation of Lateral Compartment
•
Posterior tibial cortex
as reference line
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Parallels tangent to the
posterior aspect of the
condyles
•
Distance between these
tangent lines and the
tibial compartments
Landmarks
Lateral condyle : anterior notch and posterior angle
ATMC
ATLC
Anterior radiological drawer
ATMC and ATLC
Posterior translation of the tibia
PTMC = Posterior Translation of Medial Compartment
PTLC = Posterior Translation of Lateral Compartment
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
methods
• 2100 X-ray films
• 4200 measurements
• One observer (JL L)
Methods
Interobserver intraclass correlation
3 observers
50 patients measured
(ruptured ACL -
normal knee)
Intraobserver intraclass correlation
1 observer measured 50 patients twice
Intra and interobserver intraclass correlation
for ATMC and ATLC
All values include 95 % confidence intervals
ATMC
ATLC
Normal
0.91 (0.85 - 0.95)
0.97 (0.95 - 0.98)
0.92 (0.85 - 0.95)
0.93 (0.89 - 0.96)
Deficient ACL
0.95 (0.90 - 0.98)
0.98 (0.94 - 0.98)
0.92 (0.85 - 0.95)
0.95 (0.92 - 0.97)
RESULTS
Right-left difference
38 normal subjects
Ant Transl Medial Comp :
Ant Transl Lateral Comp :
Post Transl Medial Comp :
Post Transl Lateral Comp :
0.5 ± 0.4 mm
1.2 ± 0.4 mm
1.1 ± 0.7 mm
1.5 ± 1.2 mm
RESULTS
563 normal knees
ATMC
ATLC
PTMC
PTLC
=
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=
2.1 ± 2.6
10.5 ± 3.5
2.1 ± 2.9
1.7 ± 4.1
478 ACL deficient knees
ATMC
ATLC
PTMC
PTLC
= 10.4 ± 4.3
= 18.5 ± 5.1
= 2.7 ± 2.9
= 1.1 ± 4.1
No difference between males and females
RESULTS
PTMC = 2.1
PTLC = 1.7
± 2.9
± 4.1
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No difference for posterior translation
(ACL ruptured or not )
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Posterior position is different from the
radiological "zero position"
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It is the "starting position" for clinical tests
and for arthrometric measurements
Diagnosis of ACL rupture
The ATMC is the most reliable
ATMC
Cut point :
6
mm
ATLC
Cut point :
11.5
mm
1.0
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specificity =
90 %
sensitivity =
87 %
predict posit. val = 89 %
predict negat. val = 88 %
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87%
79 %
85 %
82 %
Sensitivity
.9
.8
.7
.6
.5
.4
.3
.2
.1
.0
.0
.1
.2
.3
.4
.5
.6
.7
1-specificity
.8
.9
1.0
Physiological ant-post laxity
Medial
Compartment
PTMC +ATMC
4.2 ± 2.7 mm
Lateral
Compartiment
PTLC +ATLC
12.2 ± 4.5 mm
Pathological ant-post laxity
Medial
Compartment
PTMC +ATMC
12.1
± 4.5 mm
Lateral
Compartiment
PTLC +ATLC
19.4
± 5.5 mm
Considering differential laxity
Pathological ATMC and ATLC
Normal contralateral knee
ACL deficient knees : differential ant. translation
80
70
ATMC
8.1 ± 4.2 mm
60
50
40
30
20
10
0
-5
0
5
10
15
20
Diffe rential ATMC
80
70
ATLC
7.5 ± 4.6 mm
60
50
40
30
20
10
0
-5
0
5
10
15
20
Differential ATLC
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
Anterior laxities classification
Cases
number
%
30
25
20
15
10
5
0
<5
mm
5-8
mm
8-11
mm
>11
mm
ATMC
Anterior laxities : grade 1
Diff. Laxity mm
15
11
8
5
zero position line
Anterior laxities : grade 1
Diff. Laxity
15
ATMC
11
8
5
128
knees
zero position line
Anterior laxities : grade 1
Diff. Laxity
15
ATMC
ATLC
1D
11
1C
8
1B
5
128
zero position line
59
1A
Anterior laxities : grade 1
Diff. Laxity
15
ATMC
ATLC
1D
11
1C
8
5
128
zero position line
36
1B
59
1A
Anterior laxities : grade 1
Diff. Laxity
15
ATMC
ATLC
1D
11
8
5
128
zero position line
22
1C
36
1B
59
1A
Anterior laxities : grade 1
Diff. Laxity
15
ATMC
11
8
5
128
zero position line
ATLC
11
1D
22
1C
36
1B
59
1A
Anterior laxity : grade 2
Diff. Laxity
15
ATMC
ATLC
11
18
2D
8
25
2C
25
2B
48
2A
5
116
Zero position line
Anterior laxity : grade 3
Diff. Laxity
15
11
8
ATMC
109
5
Zero position line
ATLC
29
3D
26
3C
19
3B
35
3A
Anterior laxity : grade 4
Diff. Laxity
ATMC
ATLC
15
11
91
4D
4C
8
5
zero position line
19
4B
11
4A
Anterior laxity : grade 4
Diff. Laxity
ATMC
ATLC
91
24
4D
37
4C
19
4B
11
4A
15
11
8
5
zero position line
Anterior laxities classification
Grade 4
Grade 3
Grade 2
Grade 1
4-A
3-A
2-A
1-A
4-B
3-B
2-B
1-B
4-C
3-C
2-C
1-C
ATMC (first number) : 4 grades
ATLC (A, B, C or D) : 4 grades
4-D
3-D
2-D
1-D
Anterior laxities classification
Number of cases for all categories ( % )
Grade 4
Grade 3
Grade 2
Grade 1
2 .5
8
1 0 .8
1 3 .2
4 .3
4. 2
5 .6
8
8 .3
5 .5
5 .6
4
5. 4
6 .5
4
2
A
B
C
D
n = 487
Prospective surgery
2A
1A
isolated ACL
2B
1B
2C
1C
2D
1D
ACL + extra-articular
lateral reconstruction
Prospective surgery
ACL + medial
19 %
38 %
4A
3A
2A
1A
isolated ACL
ACL + medial + lateral
4B
3B
2B
1B
4C
3C
2C
1C
4D
3D
2D
1D
26 %
17 %
ACL + extra articular
lateral reconstruction
Precice and objective measurement of
preop and post-op laxity
Preoperative ATMC and ATLC
Post op 10 years
"Mac InJones » procedure
ACL reconstruction with patellar tendon
Quadricipital tendon is stretched from the condyle
to the Gerdy’s tubercule with solid sutures
Evolution of radiological laxity after surgery
ACL reconstruction + lateral plasty : 100 cases
9
8
7
Differential left/right laxity
6
5
ATMC
TACE
4
3
2
1
0
preop
6m
1 year > 10 y
Gain for ATMC : 62 %
Gain for ATLC : 77 %
In the same way, a prospective study is started to
evaluate postero-medial reconstruction
Conclusions
• Conclusive diagnosis for ACL rupture
• Better comprehension of laxity physiopathology
• Laxities classification
• Judicious surgical treatment adaptated to the lesions
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 insertions
using semi tendinosus or quadricipital tendon
3/ Tension without detaching the distal and proximal insertions