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
Foot print separate AM & PL BundleBut... Difficult to see the insertion
Tibial side
Gilquist 1985 JBJS A
PLB
AMB
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
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Translation under 90N anterior load (n=14) (Kondo, Amis, Yasuda, et al: Unpublished data)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
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
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