MRI use or misuse in ACL lesions

JOÃO ESPREGUEIRA-MENDES, MD, PhDA. Monteiro, H. Pereira, P. Varanda, N. Sevivas, João Pedro Araújo, Isabel Lopes,

R. Pereira, F. Brandão, M. Oliveira, RA Sousa, R.L. Reis and Niek van Dijk

Chairman and Professor Orthopaedic Department - Minho University

President of the European Society of Knee Surgery, Arthroscopy and Sports TraumaSenior Researcher of 3B`s

PORTO – PORTUGAL

MINHO UNIVERSITY PORTO UNIVERSITY ISAKOSFC. Porto

ISAKOS approved teaching center

ESSKA approved teaching center

CLÍNICA ESPREGUEIRA-MENDES - Sports CentreDragão Stadium – FC Porto

“FIFA MEDICAL CENTRE OF EXCELLENCE”

AJSM , 1993, P. Neyret and Dejour

RISK OF OA AFTER ACL INJURY &/OR RECON

RCO , 1988H.Dejour et al.

ACLR the internal–external rotation,varus–valgus

and knee flexion position of reconstructed knees

would be different from uninjured contralateral

knees during walking.

26 subjects with unilateral ACLR with data self-

selected speed in the gait laboratory.

22 out of 26 experienced an average external

tibial rotation offset through outstance phase.

These findings show that differences in tibial

rotation during walking exist in ACLR

compared to healthy contra lateral knees.

3D kinematic analysis to evaluate the functional levels ofthe knee, it has been found that in the ACL-deficientknee there is anterior tibial translation and excessivetibial rotation during everyday activities.

ACLR is successful in restoring these functions when low-demanding activities such as walking are performed.

During high-demanding activities, ACLR seems to fail torestore excessive tibial rotation, which may be the causeof further degeneration in the medial compartment evenafter ACLR.

The most common non-contact ACL injury mechanism include adeceleration task with high knee internal extension torque combinedwith dynamic valgus rotation.

Control of rotation is crucial for the performance of contact sports and football

SB ACL resulted in a significant smaller tibiofemoral contact area & higher pressures.

DB ACL more closely restores the normal contact area

(prevention of osteoarthritis)

232 acute ACL

48 Lachman grade + were treated non-op

(30 male and 18 female)

12 complete (25%) and 36 incomplete ACL ruptures (75%)

FU 21,5 M Lachman improved to grade 0 in 41 patients (87%)

36 patients (76%) showed no laxity in the follow-up LPS test

The last FU IKDC was a mean value of 91.1 points

These results suggest that a select group of patients with an acute ACL injury can successfully undergo non-op treatment.

CLINICAL EVALUATION

“THE DIAGNOSIS OF AN ACL RUPTURE IS DONE BY HAND...”

IS THIS SUFFICIENT INFORMATION TO TREAT A PATIENT WITH ACL INJURY?

Methods:12 expert surgeons examined a whole lowercadaveric extremity with their preferredtechnique and assigned a clinical grade, I–III.Anterior tibial translation and acceleration weremeasured using an electromagnetic system. Thetest was repeated after watching an instructionalvideo focused on a standardized pivot shifttechnique.

Conclusion: Several different pivot shift maneuvers are described in this article. Clinicalgrading and the magnitude of perceived PST vary between the different techniques.

In the future, a standardized PST, utilizing gentle forces and allowing motion, may bebeneficial when comparing outcomes following ACLR.

MRI – ACL LESIONS

- 90-98% Sensitivity

- 90-100% Specificity

- 90-95% Acuity

Stekel H & F. Fu, KSSTA, 2007

Jackson DW et al., AJSM, 1988

Indirect signs

- Complete interruption of fibers

- Modification of ACL direction

- Increase of ACL signal

- Disappearance of the ligament

Conclusion:

•There are significant differences in bone morphology

• Significant differences in bone morphology betweenACL-injured and non-injured subjects

•Notch width measures on MRI and arthroscopically have nocorrelation

•Condyle size is a risk factor for ACL injury – may influenceknee Kinematics

TOTAL RUPTURE

PARTIAL RUPTURE

(Imp. - 3 Tesla - 3D turbo spin-echo)

FUNTIONAL ACL OR NON-FUNCTIONAL ACL ?

We misuse MRI for the diagnosis of ACL tears

INDIRECT SIGNS - ACL TEARS

- PCL and patellar tendon waving due to anterior tibialtranslation.

- Bone bruises: usually in external condyle and posteriorexternal part of the tibial plate (remain about 9 weeks).

- Occult fractures by direct impact or capsular pullout.

STOLER

OSTEOCHONDRAL FRACTURE OF THE FEMORAL EXTERNAL CONDYLE

BONE BRUISE OF THE POSTERIOR EXTERNAL TIBIAL PLATEAU

SEGOND FRACTURE(external capsule – Gerdy)

POTENTIAL HEALING OF ACUTE ACLINJURIES IN CHILDREN

ACL INSUFFICIENCY IN A PEDIATRICPATIENT WITH A TIBIAL BONE AVULSIONNOT VISIBLE IN THE X-RAY

PEDIATRIC PATIENTS

ASSOCIATED LESIONSACL CYST & MUCOID

DEGENERATION

Based on MRI findings alone, clear separation between mucoid degenerationand partial (delaminated) tear of the ACL is not possible

Sharon H. and F. Fu, KSSTA, 2011Van Dick, P, et al., KSSTA, 2012

GRAFT EVALUATION

CYCLOPS

GRAFT POSITION

GRAFT RUPTURE TUNNEL ENLARGMENT

KT1000/2000

NO ROTATION MEASUREMENTNO MEASUREMENTS BETWEEN FEMUR & TIBIA

“GLOBAL” AP MEASUREMENT

Reliability of KT1000 and Lachman test20 patients with a complete tear of ACL were examined.Measured the anterior–posterior translation of the knee using both theKT1000 and the Lachman test.High ICCs for the intra-rater and inter-rater reliability of Lachman test.For the KT1000 arthrometer both ICCs were clearly lower.

The KT1000 arthrometer shows inadequate reliabilities, evenwhen measurements are repeated within a single measurementsession.

Is a diagnosis of partial or even total ACL rupture enough to indicate surgery in 2013 (high level football players?)

How to be sure about the functioning of the remaining bundle?

Can we correctly measure AP translation & rotation?

Can we control rotation without knowing the value of normal pattern?

Do we know how much AP translation, rotation or both combined causes instability (“cut point”)?

“A simple clinically applicable tool, similar to KT 1000 arthrometer, thatcould be used to quantify laxity and rotation needs to be developed”

J. Irrgang, J. Bost & F. Fu Letter of AJSM 2009

“ Both instrumented laxity and MRI need to be used in combinationwith proper clinical evaluation to possibly acquire a greater diagnosisvalue.” D. Dejour et al., Arthroscopy, March, 2013

Branch TP et al,

KSSTA (2009)

Robert H. et al,

Rev. COT (2009)

Tsai AG, F. Fu et al, .

BMC Muscu Disord. (2008)

T. Branch, H. Mayr, et alArthroscopy, 2010

Kubo S. et al.

Clin Orthop Relat Res.

A. Hemmerich, B. Van der Merwe, et al, C. J. Biomechanics, 2009

Porto Knee Testing Device

PORTO-KTD

ACL evaluation with IR & ER PCL PL & PM Instability

PORTO-KTD

NO PRESSUREAP TRANSLATION & I ROTATIONAP TRANSLATION

ROTATION OF KNEE -MRI EVALUATION

MEASUREMENT OF INTERNAL ROTATION OF THE TIBIA

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LATERAL TIBIAL CONDYLE TRANSLATION – MEDIAL TIBIAL CONDYLE TRANSLATION

28 cases with symptomatic andarthroscopy confirmed total

ACL RUPTURE

MRI EVALUATION with PKTD(injured + healthy knee)

KSSTA,Vol. 20, Nº 4

April 2012

Mean 33,4 ± 9.4 y

25 MALES & 3 FEMALESSEX

AGE

SIDE

2008 - 2010

MRI 1,5 T GE Healthcare Signa, USA T1,T2, STIR, FatSat, 3D SPGR

13 LEFT & 15 RIGHT

25,3 (SD = 3,1)BMI

0

2

4

6

8

10

12

14

16

FootballHandball

VolleyballRugbyOthers

Lachman test did not correlate with PKTD rotation ( MTP-LTP side toside ≠).

KT 1000 had a positive correlation with PKTD translation of MTP & LPTbut not with rotation (MTP-LTP side to side ≠).

Lateral Pivot-shift had a positive correlation with PKTD rotation

(MTP-LTP side to side ≠).

ACL “partial” rupture

Porto-KTD useful in

partial ruptures

The “chewing gum” effect with PA stress

Abnormal rotation in population at “risk”?

Comparing “healthy” vs injured knee vs normal population

Is increased rotation a risk factor?

BA

CONCLUSION

PORTO – KTD in MRI

� Identify the patients that will need/not need reconstruction

� Improve indications for partial ruptures

� Verification of remaining bundle’s (functional/non functional ACL)

� «Chewing-gum» effect

� Indications for SB or DB?

� Surgical results evaluation

� Prevention? (Is increased rotation a risk?)

� Objective evaluation of AP & rotation laxity in ACL deficient knee

AWARD “BES INOVATION 2012”

PKTD - PORTO KNEE TESTING DEVICE ®

THANK YOU!

THANK YOU!

KT 1000 versus PKTD

Comparing KT-1000 difference side to side & PKTD side-to-side difference between injured and healthy knee, we found a strong positive correlation in medial and lateral tibial plateau displacement (p <0.05).

Purpose: To evaluate the question of whether differentarthroscopically confirmed ACL injury patterns havedistinctive preoperative findings on clinical examination,instrumented laxity and MRI.

“Clinical examination is examiner dependent and theinability to produce consistent and comparable resultseven with the usual tests raises the need to use objectiveinstrumented laxity methods and to quantify the amountof laxity...”

ResultsClinical examination:

•PST grades of +2 and +3 consistent with Complete ACLtears (86%; P<.00001)

•PST grades of 0 or +1, strongly related with partial tears(76%; P<.00001)

•LT grade + 2 – statistically significant diff. Betweencomplete and partial tears (99%; P<.00001)

ResultsInstrumented laxity (Telos Stress Device):

•Significant SSD of anterior translation incomplete tears (9.1±±±± 3.4 mm) versus partialtears (5.2 ±±±± 2.9 mm; P<.0001)

•67% of PL-intact cases were “functional”with lower instrumented laxity values(SSD, 4.3 ±±±± 2.3 mm) than the “nonfunctional” cases(SSD, 6.7 ±±±± 2.9 mm; P<.001)

Rotational Laxity? Soft tissues imaging?

“Both Instrumented laxity and MRI need to be usedin combination with proper clinical evaluation topossibly acquire a greater diagnosis value.”

2013 Apr;21(4):767-83.

Quantifying the pivot shift test: a systematic review.Lopomo N, Zaffagnini S, Amis AA.

CONCLUSION:

“Several methodologies have been identified and developed to quantify pivot shift test.”

“However, clinical professionals are still lacking a 'gold standard' method for the quantification of knee joint dynamic laxity.”

“Further development of measurement methods is indeedrequired to achieve this goal in a routine clinical scenario.”

NAVIGATION

Zaffagnini 2006 Colombet 2007

152 ACL PATIENTS INCLUDED IN THE STUDY

Courtesy S. Zaffagnini

2 DIFFERENT NAVIGATION SYSTEMS with KINEMATIC ANALYSIS MODULE:BLU-IGS / KLEE (Orthokey)SURGETICS STATION / KOALA (Praxim)

Lesões da banda ilio-tibial

� Raras também geralmente associadas a outras lesões

externas.

� Pode haver avulsão óssea do tubèrculo de Gerdy

O´DONOGHUE TRIAD

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