Can Cnventinal X Ray Imaging Predict fr Anterir Cruciate Ligament Recnstructin Failure 12 th Biennial ISAKOS Cngress Cancun, Mexic 12-16 th May 2019 Adham Elgeidi, M.D. Mhammed Badran, M.D. Mansura Schl f Medicine, Mansura, EGYPT
N Cnflict f interest Adham Elgeidi, MD I have n financial cnflicts t disclse Mhammed Badran, MD I have n financial cnflicts t disclse
Aim f wrk Crrelate between radilgical parameters & clinical results f ACLR, & Cmpare between cnventinal X Ray & CT scans as tls f assessment. Study hypthesis Gd X Ray parameters wuld indicate gd clinical results, whilst Imprper X Ray parameters means unsatisfactry clinical results.
Patients and Methds Retrspective study evaluate radilgical & clinical results f Islated single bundle trans-antermedial prtal ACLR using quadruple Hamstring graft Fixed with interference screws n bth sides with > 2 years fllw up: - Knee Surgery Unit, Mansura University Hspitals, Mansura, EGYPT - Over 4 years frm January 2012 till December 2015.
A- Radilgical Assessment: Methds 1. Plain X Rays (AP & Lateral views) 2. Cmputed Tmgraphy (CT). Patient was cnsidered t have: Anatmical ACLR: bth tunnels anatmical, Nn-anatmical ACLR: B- Clinical Assessment: ne r bth tunnels nt anatmical. Orthpedic fellw wh was blind t radilgical results assessed all patients clinically: 1. IKDC scre 2. Lyshhm scre.
(Khalfayan EE et al., 1996 AJSM, Pinczewski L et al., 2008 JBJS Am, Lee JK et al., 2015 KSSTA) X Ray Tunnel psitin: 1. Tibial tunnel : ~ Lat View: 38-42% tibial plateau frm anterir ~ AP view: 47-52% tibial plateau frm medial 2. Femral tunnel : ~ Lat View: 86% f AP length f Blumensaat s & ~ AP view: 43% distance frm lateral crtex.
CT Tunnel psitin: 3D CT (Bernard Grid Methd): Anatmical femral tunnel center 20-25% depth 15-20% height. Anatmical tibial tunnel center 38-42% AP 47-52% ML. #### 100% 0% 100% D 0% H femral ftprint depth 0% very psterir t 100% very anterir height 0 % very prximal t 100% very distal (Lee JK et al., 2015 KSSTA, Xu H et al., 2016 Arthrscpy)
Results Our database 200 ACLR dne during study perid. Out f these, 70 patients hamstring tendn graft / interference screws / > 2 years fllw up. 7 patients refused t participate & 3 patients culdn t be reached 60 patients included in this study.
Crrelating bjective IKDC scre & CT data: Pstperative Radilgical data (CT) A (n=11) B (n=34) C (n=12) D (n=3) p-value Femral_3D_sagital_ view N % N % N % N % Anatmical 11 100.0 32 94.1 4 33.3 1 33.3 Nn anatmical 0 0.0 2 5.9 8 66.7 2 66.7.001** Tibia_frm ant. T pst. Anatmical 11 100.0 31 91.2 5 41.7 1 33.3.001** Nn anatmical 0 0.0 3 8.8 7 58.3 2 66.7 Tibia_medilat Anatmical 11 100.0 32 94.1 10 83.3 2 66.7 0.186 Nn anatmical 0 0.0 2 5.9 2 16.7 1 33.3 Widening Femral tunnel by traditinal methd Median (Min-Max) 2 (1-4) 3 (.0-4) 2 (0-7) 4 (3-6) 0.166 Widening Tibial tunnel by traditinal methd Median (Min-Max) 2 (.0-3) 2 (-1-4) 2 (.0-4) 3 (1-4) 0.648 Narrwing Femral tunnel at rifice -2(- 4:-1) -1.75 (- 5:0) 1 (-2.5:2) ab 2( 2-9) abc.001** Narrwing Tibial tuunel at rifice -3(- 5:-1) -2.5 (- 5:1) 1(- 3:1) ab 1( 1-6) ab.001** fem. Tunnel angle crnal 33.45±2.87 35.91±3.08 a 38.33±3.98 ab 41.67±7.23 ab F= 6.342 p=0.001* tibial tunnel angle crnal 55.00±1.18 53.38±2.65 53.67±5.56 51.33±8.50 F= 0.984 p= 0.407 tibial tunnel angle sagittal 52.45±2.62 49.76±2.86 a 51.67±3.79 43.33±11.59 abc F= 5.574 p=0.002* Graft crnal angle in degree 68.77±2.93 70.89±1.49 72.46±3.66 75.00±5.29 abc 0.016* Graft sagittal angle In degree 48.82±1.94 49.11±1.99 46.75±5.11 50.00±8.00 0.157
Crrelating CT tunnel psitin with ther CT data: (CT) AA (n=46) NN (n=9) AN (n=2) NA (n=3) Test f sig. p- value Widening femral tunnel by traditinal methd 2.50 (.00-7.00) 1.00 (1.00-6.00) 3.00 (3.00-3.00) 1.00 (.00-2.00) KW=4.49 p=0.213 Widening tibial tunnel by traditinal methd 2.00 (-1.00-4.00) 2. 00 (2.00-4.00) 3.00 (2.00-4.00) 1.00 (.00-2.00) KW=7.15 p=0.067 Narrwing femral tunnel at rifice -2.00 (-5.00-2.00) 0.0 (.00-9.00) a 1.00 (.00-2.00) a 1.00 (.00-1.00) a KW=23.57 p=<.001** Narrwing tibial tunnel at rifice -2.75 (-5.00-1.00) 1.00 (.00-6.00) a 1.00 (1.00-1.00) a 1.00 (.00-1.00) a KW=26. 84 p=<.001** fem. Tunnel crnal angle 35.82±4.12 37.22±2.49 40.50±2.12 36.66±4.04 F=1.16 p=0.330 tibial tunnel crnal angle 53.50±2.95 55.11±4.86 48.00±0.00 55.00±7.00 F=2.45 p=0.072 tibial tunnel sagittal angle 50.56±3.09 48.78±7.77 49.50±4.94 50.66±5.13 F= 0.599 p=0.618 graft crnal angle in degree 68.77±2.93 70.89±1.49 72.46±3.66 75.00±5.29 abc F= 7.68 p=<0.001** graft sagittal angle In degree 49.32±1.92 45.44±4.9 a 44.00±1.41 a 50.66±7.50 bc F=6.67 p=0.001*
Discussin Many f radilgical parameters ly crrelated t clinical utcme: 1. Anatmical tunnel psitin, 2. Orifice narrwing, 3. Tunnel inclinatin angle, 4. Graft inclinatin angle: ~ angle near hrizntal plane better clinical utcme, ~ graft inclinatin angle resembled native ACL (68.77 ± 2.93 crnal & 48.82 ± 1.94 sagittal) satisfactry N statistically difference between CT & cnventinal X ray fr assessment f ACLR tunnel psitin & widening. Nevertheless, nt all cases culd be assessed by X ray especially femral tunnel & tunnel rifice. Cases fully assessed by X ray (21 ut f 60 = 35%).
Cnclusin Satisfactry clinical utcme crrelates with prper radilgical measures f ACLR. Cnventinal X Rays can help identify ACLR failure: ~ cnstitutes a cheaper ptin than CT & ~ mre imprtantly less radiatin expsure. If X ray is nt clear & accurate (65%) d CT scan. We recmmend add radilgical parameters as part f pst-perative ACLR scrning system.
References Khalfayan EE, Sharkey PF, Alexander AH et al., (1996) The Relatinship Between Tunnel Placement and Clinical Results After Anterir Cruciate Ligament Recnstructin. AJSM ; 24(3):335-341 Pinczewski L, Salmn L, Jacksn W et al., (2008) Radilgical Landmarks fr Placement f the Tunnels in Single-bundle Recnstructin f the Anterir Cruciate Ligament. Bne & Jint Jurnal; 90(2):172-179 Lee JK, Lee S, Seng SC, Lee MC (2015) Anatmy f the Anterir Cruciate Ligament Insertin Sites: Cmparisn f Plain Radigraphy and Threedimensinal Cmputed Tmgraphic Imaging t Anatmic Dissectin. KSSTA; 23 (8):2297-2305 Xu H, Zhang C, Zhang Q et al., (2016) A systematic Review f Anterir Cruciate Ligament Femral Ftprint Lcatin Evaluated by Quadrant Methd fr Single-bundle and Duble-bundle Anatmic Recnstructin. Arthrscpy; 32 (8):1724-1734