Jan 9, 1993 - Lachman test showed. ACL rupture in 92 % of cases compared with. 70% ... tibial plateau was associated with a 6 mm increase in anterior tibial.
TIBIAL
TRANSLATION
LIGAMENT
ANTERIOR
CRUCIATE
RUPTURE
TWO
RADIOLOGICAL
HENRI
DEJOUR,
From
AJ3TER
MICHEL
Centre
COMPARED
TESTS
BONNIN
Hospitalier
Lyon-Sud,
Pierre-B#{233}nite, France
Anterior tibial translation was measured in both knees using the radiological Lachman test and the lateral monopodal stance tests in 281 patients with unilateral anterior cruciate ligament (ACL) rupture. Measurements of translation in the medial com-
by an arthrometer
partment
called
were
more
useful
than
those
in the
lateral
compartment. Measurement of anterior tibial translation in the medial compartment using the radiological Lachman test showed ACL rupture in 92 % of cases compared with 70% for the lateral monopodal stance test. In normal and in ACL-ruptured knees the monopodal stance test showed that every 10#{176} increase in posterior inclination of the tibial plateau was associated with a 6 mm increase in anterior tibial translation; the radiological Lachman test showed a 3 mm increase for every 10#{176} increase in tibial slope.
radiologically We have ment
of
Surg
Received
[Br]
l9January
1994; 1993;
76-B:745-9 Accepted
revision
16 March
1993
described
tibial
and
Singer
1989),
technique
the radiological
translation (Dejour
the radiological
or
using
et a! 1988a).
Lachman
test,
measure-
the
quadriceps
This
technique,
gives
results
which
compare well with those from a KT 1000 arthrometer (Franklin et al 1991), although the latter measures only passive translation. We now describe another method of measuring
anterior
tibial
translation
(ATT)
by radiography
while the patient stands first on the affected leg and then on the opposite leg; the two are then compared. We call this the lateral monopodal stance test. It attempts to image the knee in a more physiological mode with full vertical compression force on the tibial plateau. It is still not ideal, however, since it is static and not dynamic. The advantage of radiological methods of measure-
over
as well after
Osternig
1986).
already
anterior
contraction
ment J BoneJoint
(Harter,
(Hooper
others
is that they
as a numerical
avoid the enlargement.
problems We have
test and the lateral 1986
in the
provide
measure.
a permanent
With
care
record
it is possible
to
of rotational malalignment and used both the radiological Lachman
monopodal
investigation
stance
test routinely
of patients
with
since
rupture
of the
ACL. The Analysis knee 1989) nents,
of the forces
in the sagittal
leads
movement 1976;
of the extended
(Williams and Lissner 1977; Nordin and shows that they can be resolved into two a vertical compression force on the tibial
and a shearing force The primary restraint the anterior cruciate
ACL
plane
Slocum
that tends to move the tibia anteriorly. to anterior movement of the tibia is ligament (ACL) and rupture of the
to abnormal can
be
anterior
measured
et al 1976;
tibial
clinically Galway
and
©l994 British 0301-620X/94/5634
VOL.
should Editorial
be sent
Society $2.00
76-B. No. 5. SEPTEMBER
to Professor of Bone
1994
has
been
(1983,
of the
(tibial
slope)
demonstrated 1984).
the performance slope
anterior
tibial
by
of rupture
ligament,
from
inclination
in dogs
In cases
the
tibial
posterior
on anterior
Slocum of the
of a tibial
a mean
Shoemaker
and Markolf(1986)
found
et al
medial meniscus, vertical compression tibia to move forward. This was due,
after
Centre
Surgery
Hospitalier
division
of
the
ACL
and
to change
that
the
congenital
of the
medial
meniscus.
ACL
Anterior
of
the
alone caused the they thought, to the
of the tibial plateau. (1990) reported a case
absence
in cadaver
removal
posterior inclination Dejour et al
of the
Devine cruciate
laxity.
(Hughston
1980),
and cranial
osteotomy
knees,
MacIntosh
of the
translation
of 22#{176} to 0#{176} diminished
This
H. Dejour. and Joint
importance
plateau
translation.
H. Dejour, MD, Professor of Orthopaedic Surgery M. Bonnin, MD, Assistant Service de Chirurgie Orthopedique et Traumatologique, Lyon-Sud, F-69310 Pierre-B#{233}nite, France. Correspondence
Frankel compoplateau
tibial
associated
tibial
of
bilateral
with
absence
translation
was
possible to 30 mm, and the tibial slope was 28#{176}. An ACL was constructed using a free graft of the patellar ligament and an extension tibia! osteotomy was performed to
correct
the tibial slope. We present an analysis
ofthe
measurements
obtained 745
746
H. DEJOUR,
from
the radiological
Lachman
stance
test
in cases
effects
of the
normal
and ACL-deficient
PATIENTS
of ACL
tibial
slope
and
the monopodal
We
on anterior
also
tibia!
report
the
translation
in
knees.
METhODS
AND
Between
test rupture.
M. BONNIN
January
1986
and
January
1988,
445
patients
were operated on for chronic ACL rupture (more than two months after injury) at the Centre Hospitalier LyonSud. We excluded those with bilateral ruptures (operated or not), those whose treatment did not include a complete intra-articular examination (extra-articularprocedures that did not include arthroscopy), and those without acuate notes or radiographs. We therefore studied 281 patients. There were 171 men and 110 women; their mean age
at operation
right not
knees been
was on
12 had
in 45
corner
there
in two
confirmed lesion
of
There
had
had
ACL-plasty Fig.
in
of the lateral
monopodal
stance
test.
was
There
99
technique
of the
the diagnosis
arthrotomy.
meniscus
The
meniscotibial
of the origin
In these
posteromedial
rupture
1
posteromedial
ofthe
detachment
in 43.
medial
previous operations.
in 24 knees,
in the
was rupture
160
228 had
one
three
performed
a lesion
and
capsule the
were
reconstruction in 6. was an isolated ACL
also
patients by
38
and 3 had had
ACL there
was
posteromedial
There
Of these,
in 6, an extra-articular
of the knee.
fibres
to 42).
had been
meniscectomy
in 15, and a synthetic In 1 13 patients and
before,
had two,
meniscectomy
lateral
(16
and 121 left knees.
operated
operation,
Medial
25 years
affected
was
patients:
32
a had
peripheral detachments, 25 bucket-handle tears, and 18 complex tears (fissuring and flaps of the posterior horn). There were 15 lateral and 9 bilateral meniscal tears. All the patients
had
radiological
Lachman
andteral
monopodal stance tests on both knees. The lateral monopodal stance test. The patient stands on one leg with the knee flexed to 20#{176} (Fig. 1). The X-ray plate
is placed
20 cm situated
on
the
inner
side
of the
knee
to include
of the upper tibia on the film. The X-ray source is one metre from the knee and is aligned
perpendicular
to the long
of the femoral
condyles
axis
ofthe
limb.
is obtained
Superimposition
by using
an image
intensifier.
Radiological made
by
measurements. one
observer
(MB)
way. A line was to the posterior
drawn border
reference
measurement
for
the
All the measurements and obtained in the
were same
Fig.
on the radiograph perpendicular of the upper tibia to act as a of anterior
displacement.
Two lines were drawn parallel to the reference line and tangential to the most posterior part of each femoral condyle (Fig. 2). Two further lines were drawn parallel to the above tangent to the most posterior parts of the medial and
lateral
larger
tibial
and flatter
middle plateau
of its curve. is square
conical
(Jacobsen
plateaux.
The
lateral
femoral
and has the condylopatellar
condyle
sulcus
is
in the
The posterior part of the medial tibia! compared with the lateral which is
1976;
Hooper
1986).
2
The radiological measurement of medial anterior tibial translation (MATEMS) in a monopodal stance test on a patient with chronic anterior laxity of one knee. On the right knee which had ACL rupture and a damaged medial meniscus, the MATE-MS was 10 mm, on the left (normal) knee it was 2 mm, giving a difference of 8 mm.
The distance between the femoral and tibia! lines on the medial side was called the medial anterior tibia! translation (MATT) and the distance on the lateral side, the lateral anterior tibial translation (LATI’). Comparison between
tial medial
the affected
and lateral
and
normal
anterior
knees
tibia!
THE JOURNAL
gave
the differen-
translations
OF BONE
AND JOINT
(iMA1T SURGERY
TIBIAL
TRANSLATION
AFTER
ANTERIOR
CRUCIATE
RUFTURE
LIGAMENT
747
and ALA1T). To distinguish between the results of the radiological Lachman test and the monopodal stance test the suffix -RL or -MS was added, i.e., MA1T-RL or MAlT-MS. The posterior inclination of the tibia! plateau was measured as follows. The diaphyseal axis of the tibia was drawn between two points equidistantbetween the anterior and posterior borders of the tibia, one just below the tibia! tubercle and the other 10 cm below this. A reference line was drawn perpendicular to this at the level of the tibiofemoral
joint
drawn
the most
from
posterior surface).
(Fig.
3). The
inclination
superior
points
edges of the medial The angle of this line
tibia! plateau to the reference
defined as the tibia! slope. Statistical analysis. All data were compatible computer and analysed program. The differences between were
studied
using
parametric
of the tibia
was
at the anterior
stored
and
(dished line was
on
an
IBM-
using the SPSS/PC the various groups
analysis
of variance.
For
comparison of more than two groups, Scheffe’s method of multivariate analysis was used. Al! the results were recorded
as the mean
value
and
standard
deviation. DIAPHYSEAL AXIS
RESULTS Anterior
both
Fig.
tibia!
translation
the normal
and
was
found
the damaged
to vary
knees
(Figs
widely
in
The method slope.
4 and 5).
of
3
measurement
of
the
tibial
Cl)
C
0
a .0
E
z
-6-4-20
2 Anterior
4
6
Fig. Medial anterior tibial test on 281 patients.
8 iJ translation
tibial
translation
Anterior
by
in the lateral
compartment
than
medial,
in the
the
damaged
radiological
was
Lachman
always and
larger
the
normal
knees. The mean difference between the normal and the damaged knees was significant for both compartments of the
knee,
both
for
the
radiological
Lachman
(p < 0.001) and the monopoda! stance test (p ACL rupture had a proportionately greater effect media! than on the lateral side. The mean values various radiological measurements for the whole group are given in Table I. VOL
76-B. No. 5,
SEPTEMBER
1994
tibial
translation
(mm)
Fig. S
measured
both
1.
(mm)
4
Translation in the
12
test
2 mm compared with 70%) and we used the latter test more to
translation
2.9 a 3.2
3.5
M. BONNIN
test
decide
a 4.4 ±
on
AMAlT bearing
of
5.7
2 mm
Patients
were
with
a
non-weight-
on the injured leg for 45 days; those with AMAIT 2 mm were allowed to bear weight immediately after
the operation.
It is clear translation
normal
translation translation normal and ACL-ruptured
management.
preoperatively
slope
knee
that one of the factors
of the tibia
knees
the
of the tibia,
is the slope
laxity and
affecting of this
increases
at the same
the anterior
plateau.
in proportion rate
Even
in
to the
as in ACL-ruptured
15
C
0
10
CD Cl) C CD
A
5
CD
.0
.
0
0 C CD
ACL rupture
L Normal
a
-5
CD
0 a
-10 25
Tibial
slope Fig.
Correlation monopodal
difference
between the slope stance (see text).
of up to 9#{176} between
patient. There was the mean anterior
both
in the normal
(Fig.
6); the greater
anteriorly.
the two knees
of the
tibial
of the same
a highly significant tibia! translation
correlation between and the tibia! slope, and in the damaged knees (p < 0.0001) the slope the more the tibia translated
Linear
regression
analysis
resulted
in
two
(degrees)
6
plateau
and
knees; by an
medial
anterior
tibial
loss of the ACL absolute amount.
weight-bearing compression component; tibial slope
translation
simply The
in
increases the displacement forces on the knee during
can be resolved into a vertically directed component, and a horizontally directed shear it is the shear component (Shoemaker and Markolf
that varies 1986).
with
the
and one for ACL-ruptured knees. For every 10#{176} increase in tibia! slope, there was a 6 mm increase in anterior tibia! translation on monopodal stance. In the radiological Lachman test, regression analysis showed the same
The normal knee is lax, but not unstable. Excessive laxity (in extension) is probably the mechanism that leads to osteoarthritis in ACL-ruptured knees (Dejour et a! 1987, 1988b) but reconstructing the ACL can hasten rather than delay the onset of osteoarthritis (Feagin,
correlation
Cabaud
separate
tibia!
but
nearly
but
translation
parallel
with
only
for every
lines,
one
3.5 mm
of
10#{176} increase
for
healthy
increased
in tibial
knees
anterior
slope.
DISCUSSION Since tion
normal it is logical
knees
show
to measure
physiological laxity
anterior
by comparing
translathe ACL-
ruptured knee with the contralateral normal knee. As has been found in other studies (Dejour et al 1988b; Reuben et a! 1989), measuring the medial tibiofemoral compartment is more useful than measuring the lateral compartment since the range of results is smaller and the effect of an ACL rupture larger on the media! side. The
radiological
Lachman
test
was
better
than
and
Curl
1982;
Bartlett
et al 1984; Fried et al 1985; Goutallier et a! (1986)
the
reviewed
series
of
osteotomy
for
medial
and
Zarins and
patients
Crow
1984;
Johnson
and Rowe 1988). Hernigou et al (1987)
undergoing
compartment
valgus osteoarthritis,
tibia! and
found that those with a tibia! slope of 10#{176} to 15#{176} had central plateau erosions, whereas those with 18#{176} to 25#{176} had posterior erosions. They measured the slope by Moore’s technique (Moore and Harvey 1974) which gives a normal value of 14#{176}. In cases of excessive slope, the osteotomy suggesting
did that
not halt in those
perform both extension Conclusion. Anterior
the progress knees it may
of be
the arthritis, necessary to
and valgus tibia! osteotomy. tibia! translation secondary to ACL THE JOURNAL
OF BONE
AND JOINT
SURGERY
TIBIAL
rupture is recorded the medial than
and measured on the lateral
radiological
Lachman
monopodal ACL.
stance
slope
TRANSLATION
radiologically side of the
test is of more
test
When weight-bearing, is associated with
value
in demonstrating
ANTERIOR
AFTER
than
better on joint. The
of the
every 10#{176} increase in tibial a 6 mm increase in anterior tibia!
LIGAMENT
translation, ruptured greater
the lateral
rupture
CRUCIATE
both ACL,
RUPTURE
749
in normal but
the
knees
and
magnitude
in those
of the
with
displacement
a is
in the latter.
The authors thank Simon T. Donell, Senior Lecturer and Honorary Orthopaedic Consultant, Royal National Orthopaedic Hospital, Stanmore, for his help in the preparation of this paper. No benefits in any form have been received or will be received from commercial party related directly or indirectly to the subject of this article.
a
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