tibial translation aj3ter anterior cruciate - Journal of Children's ...

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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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