Evaluation of the accuracy of Lachman and Anterior Drawer Tests with KT1000 ın the follow-up of anterior cruciate ligament surgery

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1 Oiginal Aticle Jounal of Execise Rehabilitation 2016;12(4): Evaluation of the accuacy of Lachman and Anteio Dawe Tests with KT1000 ın the follow-up of anteio cuciate ligament sugey Beki Eay Kilinc 1, *, Adnan Kaa 2, Haluk Celik 3, Yunus Oc 4, Savas Camu 5 1 Othopaedics, State Hospital, Igdi, Tukey 2 Othopaedics, Istanbul Medipol Univesity, Istanbul, Tukey 3 Othopaedics, State Hospital, Zonguldak, Tukey 4 Sisli Hamidiye Etfal Taining and Reseach Hospital, Istanbul, Tukey 5 Othopaedics, State Hospital, Catalca, Tukey Ligament laxity measuement is clinically valuable to diagnose the injuy and also to compae the laxity befoe and afte sugical pocedue. The aim of the study was to compae the accuacy of the Lachman and Anteio Dawe Tests to evaluate the knee examination with the KT1000 athomete afte the anteio cuciate ligament (ACL) sugey in ealy follow-up peiod. Fouty ACL econstucted knees wee examined with the Lachman and Anteio Dawe Tests, and KT1000 athomete with compaiable intact knee of the same patients. Physical emanination findings wee compaed with the KT1000 athomete with each powe. Speaman coelation and eceive opeating chaacteistic (ROC) analysis wee used fo the evaluation of elations between paametes. Significance was evaluated in P< 0.1 and P< The mean age was 28.18± 6.21 y, and the mean follow-up was 23.09± 9.08 months. The mean KT1000 measuements of 40 opeated knees state at 6.8, 9.1, 13.6 kg and maxium anteio displacement foces wee 4.9, 6.7, 8.7, and 11.9 mm, espectively. The same values fo the same acting foces of intact knees wee 4.2, 5.9, 7.8, and 10.2, espectively. In Speaman s coelation and ROC analysis at 13.6-kg powe on KT1000 athomete statistically matched with pyhsical examinations (P< 0.1, P< 0.01). In ou study, coelation of physical examinations with KT1000 athomete is a wothy evaluation technique that can be added to examination of ACL econstucted knee to contol with inexpeinced examines findings. We suggest that at 13.6-kg powe with KT1000 athomete findings pefectly match the Lachman and Anteio Dawe Tests of the knee. Keywods: Lachman test, KT1000 athomete, Anteio Dawe Test, Anteio cuciate ligament, Anteio displacement, Knee examination INTRODUCTION The anteio cuciate ligament (ACL) is the most fequently disupted ligament in the human knee (Johnson, 1982). Measuements of the integity of knee ligaments ae used to diagnose injuies as well as to document the state of ecovey. Ligament laxity measuement is clinically valuable to diagnosis injuy and also to compae laxity befoe and afte sugical pocedue. Howeve, few studies have examined the eliability of clinical methods o instuments used to measue anteio-posteio laxity. The Lachman test is chaacteized as the most diect and definitive evaluation examination used to detemine the status of ACL (Benjaminse et al., 2006; Cimino et al., 2010; Scholten et al., 2003). Anteio Dawe Test is also an accuate test fo detecting ACL tea to evaluate anteio displacement of tibial manually a sensitivity of ACL teas (Calmbach and Hutchens, 2003). The KT1000 (MEDmetic Cop., San Diego, CA, USA) is a mechanical joint athomete allowing fo stabilization of the femu with concuent instumented assessment of the lowe leg (Daniel et al., 1985; Malcom et al., 1985). The aim of the study was to compae the accuacy of the Lachman and Anteio Dawe Tests to evaluate the knee examination with the KT1000 athomete afte sugey in ealy follow-up peiod. *Coesponding autho: Beki Eay Kilinc Othopaedics, State Hospital, Mehme Akif Mah.23 Nisan Cad.No:66/2 Bucak/ Budu 15300, Igdi, Tukey Tel: , Fax: , deaykilinc@gmail.com Received: May 6, 2016 / Accepted: July 14, 2016 This is an Open Access aticle distibuted unde the tems of the Ceative Commons Attibution Non-Commecial License ( which pemits unesticted non-commecial use, distibution, and epoduction in any medium, povided the oiginal wok is popely cited. Copyight 2016 Koean Society of Execise Rehabilitation pissn X 363 eissn

2 MATERIALS AND METHODS Fouty patients wee included the study. All patients signed a consent fom afte the test pocedue was thooughly explained. The patients had no epoted histoy of e-injuy in thei involved knees. The patients included in the study who had minumum 6-month follow-up peiod and had the same sugey technique pocedue. Thee was no involvement of the posteio cuciate ligament injuy as detemined by a negative posteio sag test that was administeed pio to each opeation. All patients ageed via infomed consent to paticipate in the investigation. The study was appoved by the Institutional Review Boad. Fouty ACL econstucted knees wee examined with the Lachman and Anteio Dawe Tests and KT1000 athomete with compaiable intact knee of same patients. Thee examines wee included the study. One othopaedic sugeon had 12-y expeience with evaluating knee stability and othe had 9-y expeience. The licensed physical theapist had 25-y expeience with knee stability. The examinations wee conducted with each examine blind to the othe s findings. Afte enollment, each patient was bought to the oom whee the test wee conducted. The active dawe test pefomed to the patient with knee flexed at 90, hip at 45 and foot stabilized on the fim examination table. While the foot was stabilized on the examination table and the hamstings wee elax, fequent manual gentle anteo-posteio foces wee applied to the poximal tibia, and tibia anteoposteio displacement in flexed knee was measued and ecoded by the nuse based on Intenational Knee Documentation Committee (IKDC) Knee Examination Fom. The Lachman test was pefomed with the patient lying supine on a fim examination table and knee flexed to degees. The examine s uppe hand stabilized the unsuppoted distal thigh, while the lowe hand, and findes feeling to ensue that the hamsting wee elaxed, pulled the tibia fowad. Anteio tanslation of tibia was measued and noted by same nuse based on IKDC Knee Examination Fom. Afte the manual examination each patient was evaluated with the KT1000 athomete to ecod the milimites of anteio tanslation at 6.8, 9.1, 13.6 kg and the maximum powe of foce. The athomete attaches secuely to the anteio leg with two staps. The athomete detects motion between two senso pads, one in contact with the femu and the othe in contact with the tibial tubecule. With a foce-sensing handle, the examine applies anteio and posteio displacement loads. The athomete emits an audible sound when 6.8, 9.1, 13.6 kg and maximum powe foce applied though the foce handle. Two suppot platfoms ae necessay fo the examination-a thigh suppot platfom fo positioning both knees of the patient in degees of flexion and a foot suppot platfom platfom fo maintaining both feet 15 degees fom midline with the hips in extenal otation. The examines applied an anteio foce by pulling slowly and smoothly on the foce-sensing handle until fou-consecutive audible tones indicated the each foces had been eached. Thee tials of each measuement wee completed. Measuements wee noted by the nuse based on IKDC Knee Examination Fom. Patients wee instucted to elax between each tials. Athomete was emoved and also placed on the contalateal knee. All examinations on one patient wee pefomed by each of thee examines. Fo each patient the uninvolved knee was evaluated fist in ode to establish a baseline by which the contalateal knee could be utilizied. Evey examine followed the same examination pocedue. Examines paid attention to ensue the both knees wee in the same degee of flexion duing the physical examination pocedue. All physical emanination findings wee compaed with the KT1000 athomete with each powe. PASS (Powe Analysis and Sample Size) 2008 Statistical Softwae (NCSS, LLC, Kaysville, UT, USA) pogam was used fo statistical analysis. Data wee analyzed by using desciptive statistical methods (mean, standad deviation, median, fequency, atio, minimum, maximum) and fo compaing quantitative data Student t-test was used fo thee goups compaison of paametes with nomal distibution, while Mann Whitney U-test was used fo thee goup compaisons of paametes without nomal distibution. Speaman coelation analysis was used fo the evaluation of elations between paametes. Significance was evaluated in P<0.01 and P<0.05. RESULTS The mean age of patients was 28.18±6.21 y (ange, y), and the mean follow-up was 23.09±9.08 months (ange, 9 42 months). Demogaphic infomation is pesented in Table 1. The mean KT1000 measuements of 40 opeated knees state at 6.8, 9.1, 13.6 kg and maxium anteio displacement foces wee 4.9, 6.7, 8.7, and 11.9 mm, espectively. The same values fo the Table 1. Desciptive chaacteistics Chaacteistic Mean± SD (ange) Age (y) 28.18± 6.21 (17 40) Follow-up (mo) 23.09± 9.08 (9 42) SD, stnadad deviaiton

3 Table 2. KT1000 measuement on opeated and intact knees same acting foces of nonopeated knees wee 4.2, 5.9, 7.8, and 10.2 (Table 2). All seven patients had ACL laxity with physical exams and also with the KT1000 athomete at 13.6-kg powe. Those patients findings wee checked by magnetic esonance imaging. The esults poved the ACL failue. Speaman coelation test showed that thee was a significant coelation between KT1000 athomete device at 13.6-kg powe and Lachman and Anteio Dawe Tests (P<0.1 and P<0.01, espectively) (Table 3). In eceive opeating chaacteistic analysis at 13.6-kg powe on KT1000 athomete cetainly matches with pyhsical laxity examination tests (P<0.1) (Table 4, Fig. 1). Thity pound on KT1000 athomete was the only one powe that had statistically significancy. DISCUSSION KT kg 9.1 kg 13.6 kg Max powe Opeated (mm) Intact (mm) The KT1000 (MEDmetic Cop., San Diego, CA, USA) is a mechanical joint athomete. Table 3. KT1000 athomete compaison with Lachman and Anteio Dawe Tests (n= 40) Diffeance opeated and intact Lachman Anteio dawe 6.8 kg 9.1 kg 13.6 kg Max powe * ** The KT1000 (MEDmetic Cop., San Diego, CA, USA) is a mechanical joint athomete., Speaman coelation atio. *P< **P< Table 4. Receive opeating chaacteistic analysis of compaison of KT1000 athoomete with Lachman and Anteio Dawe Tests Aea unde the cuve Aea SE 95% CI KT1000 (6.8 kg) KT1000 (9.1 kg) * KT1000 (13.6 kg) KT1000 (maximum powe) * Anteio Dawe Lachman The KT1000 (MEDmetic Cop., San Diego, CA, USA) is a mechanical joint athomete. SE, standad eo; CI, confidence inteval. *P< Sensitivity ROC cuve Souce of the cuve KT1000 (6.8 kg) KT1000 (9.1 kg) KT1000 (13.6 kg) KT1000 (maximum powe) Anteio dawe Lanchman Refeence line Specificity Fig. 1. Receive opeating chaacteistic (ROC) analysis of compaison of KT1000 athoomete (MEDmetic Cop., San Diego, CA, USA) with Lachman and Anteio Dawe Tests. Afte ACL uptue, most patients have detectable signs and symptoms of excess knee laxity and the joint becomes unstable. Anteio tibial tanslation in nomal knees has vey little diffeent in ight and left knees and in 95% of nomal population; this diffeence is less than 2 mm. It is cucial to use the contalateal nomal knee as contol to compae the diffeence in laxity between nomal and injued knees (Shelboune, 2010). In a clinical examination, the anteio displacement of the tibia on the femu is based on a subjective evaluation of ACL disuption o anteio instability. Seveal manual tests ae available to detemine whethe the ACL has been injued and also to evaluate stability of ACL at follow-up peiod. The classical test fo ACL deficiency, the Lachman and Anteio Dawe Tests ae pefomed based on evaluation of the anteio instability (Solomon et al., 2001). Liu showed that the sensitivity of Lachman and Anteio Dawe Test was 95% and 61%, espectively. Lachman test sensitivity eaches up to 100% unde anesthesia (Liu et al., 1995). They ae ae the subjective evaluations most fequently used to assess ACL instability

4 Most commonly used devices available to assess ligament integity ae designed to assess the cuciate ligaments because they ae accessible fo testing and because they ae impotant in maintaining knee stability. The Knee Athomete KT1000 is a commecially feasible instument designed to povide and objective measuement of anteio-posteio laxity (Bach et al., 1990; Daniel et al., 1985; Daniel and Stone, 1990; Woble et al., 1990). A study epoted in 21 patients that KT1000 athomete can not be coelated with the clinical findings. They suppoted doubt on the accuacy and usefulness of the KT1000 (Gaham et al., 1991). Moe ecently, testing of knee ligament integity with devices such as the KT1000 athomete has gained inceasing populaity. The KT1000 is a useful tool, as it is easy and fast to handle by an expeienced examine. Supplementay to noninvasive diagnostical methods it impoves the confidence in clinical diagnosis. Howeve, the impotance of instumental measuement should not be oveated even though epoducible esults can be obtained. To compae the esults of diffeent studies the design has to be vey simila. It is impotant to know the accuacy of test used to establish a follow-up note in patients with knee stability. So fa, thee is no study has consideed to coelate the physical examination test with the insumented examination at follow-up peiod of patients who had ACL econstuction sugey. In ou study, physical tests sensitivities cetainly matched with the instumented test KT1000 at 13.6-kg powe. Theefoe, the inexpeienced examine s intepetation could dop the sensitivity of these tests, egadless of which examine findings could check with KT1000 instumented examination. As fo geneal pactitiones who ae less expeienced in caying out these physical tests, they can cetainly contol thei examination findings with the 30 pound powe on KT1000 athtomete. This suggests that the eseved and equivocal physical test findings can be coalated with the KT1000 athomete afte ACL sugey follow-up peiod. With KT1000 instument measuements ae accuate in indicating anteio knee laxity, we tied to coelate the physical examinations of anteio-posteio laxity with KT1000 athomete device. Taken into consideation, ou esults epot that the accuacy of KT1000 athomete device at 13.6-kg powe was statistically coelated to the Lachman and Anteio Dawe Tests. Based on the follow-up pefomance in ou study, coelation of physical examinations with KT1000 athomete is a wothy evaluation technique that can be added to examination of ACL econstucted knee to contol with inexpeinced examines findings. We suggest that at 13.6-kg powe on KT1000 athomete findings pefectly match the Lachman and Anteio Dawe Tests of knee. CONFLICT OF INTEREST No potential conflict of inteest elevant to this aticle was epoted. REFERENCES Bach BR J, Waen RF, Flynn WM, Koll M, Wickiewiecz TL. Athometic evaluation of knees that have a ton anteio cuciate ligament. J Bone Joint Sug Am 1990;72: Benjaminse A, Gokele A, van de Schans CP. Clinical diagnosis of an anteio cuciate ligament uptue: a meta-analysis. J Othop Spots Phys The 2006;36: Calmbach WL, Hutchens M. Evaluation of patients pesenting with knee pain: Pat I. Histoy, physical examination, adiogaphs, and laboatoy tests. Am Fam Physician 2003;68: Cimino F, Volk BS, Sette D. Anteio cuciate ligament injuy: diagnosis, management, and pevention. Am Fam Physician 2010;82: Daniel DM, Stone ML. KT-1000 anteio-posteio displacement measuements. In: Daniel DM, Akeson WH, O Conno JJ, editos. Knee ligaments stuctue, function, ınjuy and epai. New Yok: Raven Pess; p Daniel DM, Stone ML, Sachs R, Malcom L. Instumented measuement of anteio knee laxity in patients with acute anteio cuciate ligament disuption. Am J Spots Med 1985;13: Gaham GP, Johnson S, Dent CM, Faiclough JA. Compaison of clinical tests and the KT1000 in the diagnosis of anteio cuciate ligament uptue. B J Spots Med 1991;25: Johnson RJ. The anteio cuciate: a dilemma in spots medicine. Int J Spots Med 1982;3: Liu SH, Osti L, Heny M, Bocchi L. The diagnosis of acute complete teas of the anteio cuciate ligament. Compaison of MRI, athomety and clinical examination. J Bone Joint Sug B 1995;77: Malcom LL, Daniel DM, Stone ML, Sachs R. The measuement of anteio knee laxity afte ACL econstuctive sugey. Clin Othop Relat Res 1985;(196): Scholten RJ, Opstelten W, van de Plas CG, Bijl D, Deville WL, Boute LM. Accuacy of physical diagnostic tests fo assessing uptues of the anteio cuciate ligament: a meta-analysis. J Fam Pact 2003;52: Shelboune KD. The at of the knee examination: whee has it gone? J Bone Joint Sug Am 2010;92:e

5 Solomon DH, Simel DL, Bates DW, Katz JN, Schaffe JL. The ational clinical examination. Does this patient have a ton meniscus o ligament of the knee? Value of the physical examination. JAMA 2001;286: Woble RR, Van Ginkel LA, Good ES, Noyes FR, Shaffe BL. Repeatability of the KT-1000 athomete in a nomal population. Am J Spots Med 1990;18: