Anterior CruciateLigament Anatomy

David DejourCOROLYON Sauvegarde

Anatomy – X- Rays – Practical data

Thank you to Dr Chambat-Panisset for

Slides and Knowledge

Before After

Double bundle “Buzz”

Amis- Fu –Zantop……

°°

°

°°

°

°

A

B

P Chambat 2002

°°

°

°°

°

°

A

B

P Chambat 2002

From Femur 18 mm to Tibia 17 mm

Femoral side

Girgis,1975. Arnoszky,1983. Odensten 1985

18

17

>20° 11 mm

18 mm

AM & PL Bundle

Femoral side

F. Fu

The femoral insertion changes the length and the orientation of both bundles

AM & PL Bundle Video analysis

Femoral side

PL Bundle Video analysis

Femoral side

Foot print separate AM & PL BundleBut... Difficult to see the insertion

Tibial side

Gilquist 1985 JBJS A

PLB

AMB

Foot print separate AM & PL BundleBut... Difficult to see the insertion

Tibial side

A

A

A

M

MM

0°

70° 140°

AM fibers ≈ IsometricPL fibers ≈ Non isometric

ACL & PCLFour Bars system

P

L

P

L

PCL

P

L

P. Chambat

• Antero Medial :- Control Anterior Tibial Translation after 30° of fl exion.

- Poor control the rotation.

• Postero Lateral:- Control ATT from 0° to 20°, and the internal rotati on.

- Control rotational laxity

Amis 1991, Gabriel 2004, Amis 2005, Zantop 2007

Biomechanic of 2 Bundles

PL Bundle Rotational controlExperimental Test

Anterior Tibial Translation & Knee flexionDepending on AM or PL

PL IntactAM IntactNormal knee

Translation under 90N anterior load (n=14) (Kondo, Amis, Yasuda, et al: Unpublished data)

Zantop, et al: Am J Sports Med, 2007Cadaver knees; Sequential resection

Robotic manipulator

• AMB -resectedknee : Close to intact knee 30°• PLB-resectedknee: Close to complete tear 30°

Hole, et al: Am J Sports Med, 1996• Fresh lower extremities (cadavers)

– Close to clinical condition– KT -1000 and bi-planar radiography:

• Sequential resection– Intact– PLB-resected– “PLB+1/2 AMB”– Completely resected 0

5

10

15

Intact PLB +½AMB

Anterior translation (avg.)

PLB Complete

mm

• Resection of the PLB does not significantly increase AT• Resection of the “PLB and 1/2 AMB” significantly increases AT

Femoral Insertion

ACL tear = Anterior Tibial Translation

How to measure the ATT ?

ATT

Clinical EvaluationPivot Shift Test : Rotational evaluation

Negative + or ++ Explosive

Normal ACL Partial or Total ACL ???

Biomechanic & ACL rupture

Center of rotation changes

Increase anterior tibial translationIncrease lateral compartment mobility

Medial Lateral

Ant

Monopodal Weight bearing X rays(fluoroscopy true sagittal)

Stress X rays 15 Kg AP translation(Side to side)

Diagnostic value of instrumented laxity ?Differentiation completeand partial ACL tears

Prospective study

• 300 ACL Tears• Clinical tests• Stress X Rays side to side • Quality of the remnant (arthroscopic)

1 Complete tears59 %

2 Postero-Lateral bundle Intact22%3 PCL healing 12%4 Antero-Medial bundle intact 7%

4 categories

ACL per operative StatusResults

Arthroscopic evaluationGood quality : Functional

Bad quality : Non Functional

Partial tears 41%

Anterior Tibial Translation: TelosTM

ACL injury pattern Telos™ measurements

Average results of anterior tibial translation.

MATT LATT

Complete tear 9.1 mm 9.4 mm*

All partial tears 5.6 mm 5.6 mm

AM intact 5.1 mmNS 4.7 mmNS

PL intact 5.0 mmNS 5.2 mmNS

‘PCL healing’ 7.0 mmNS 6.9 mmNS

Complete ACL is significantly different from Partial P<0,00001

No difference between the different types of Partial tears P<0,05

Medial compartmentLateral compartment

Side to side

Evaluation of ACL laxity: Clinical tests

ACL injury

pattern

Clinical examination of knee laxity

Lachman Pivot shift

Delayed Soft Equal Glide Clunk Gross

Complete tear 1% 99% 2% 12% 48% 38%

AM intact 68% 32% 37% 42% 5% 16%

PL intact 25% 75% 23% 47% 28% 2%

‘PCL healing’ 56% 44% 20% 65% 15% 0%

Complete ACL is significantly different from Partial P<0,00001

No difference between the different types of Partial tears P<0,05

Evaluation of ACL laxity: MRI analysis

ACL injury pattern

Pre-operative MRI findings

Absence of ACL

fibers

Visible fibers Fibers on PCL

Complete tear 96% 1%* 3%*

AM intact 50% 44% 6%

PL intact 85% 3% 13%

‘PCL healing’ 71% 12% 18%

Standard static MRI cannot make the diagnosis of a partial tear !

Amount of “side to side” ATTranslationSensitivity of 0.88Specificity of 0.96

1 Keep the preserved bundle

2 Do a ACL augmentation

StandardACL

reconstruction+/_ extra-

articular plasty

Pivot Shift 0 or 1+

Functional remnant

Functional remnant

No remnant No remnant

1 Keep the Anatomic insertions

2 Do a standard ACL reconstruction

Pivot Shift 2+ or 3+

9

m

9mm

Partial ACL

0

m

0mm

4

m

4mm Complete

ACLNON

Functional remnant

NONFunctional remnant

Is only the ACL damaged in these knees?

The Antero Lateral L igament

Claes et al. Journal of anatomy 2013Dodds et al. The Bone and Joint Journal 2014

BUT …

Names Author(s)

Anterolateral ligament Vieira et al. Vincent et Neyret. Claes et al.Dods et al.

Anterior oblique band Campos et al.

Capsulo-osseous layer of iliotibial tract Terry et al

Lateral capsular ligament Dietz et al. Johnson

Mid-third lateral capsular ligament Hughston et al.,LaPrade et al. Goldman et al.

Many differents Names, Locations, Authors…

(Dods JBJS 2014)

Paul Segond1879

May 8th 1851-October 27th 1912Avulsion = pathognomonic for ACL#

Recherches cliniques et experimentales sur les epanchements sanguins du genou par entorse (Paris)

70’ and 80 ‘ Combined procedure• ACL reconstruction • extraarticular plasty

• Mac Intosh,• Mac Injohns,• KJ+Lemaire

Extra articular Plasty: « Lemaire »

La Plastie antero latéral: Marcel Lemaire 1967• 18 cm of strip fascia lata

• Isometrique, under LCLLosee, Andrew, Ellison, Imbert

1967

There is not only “a” ACL tear …

Not the same

patient

ACL Tear

Will YOU do the same treatment ??

18 mm

5 mm