The effect of the increased posterior tibial slope on the integrity of the anterior cruciate ligament and patterns of the meniscal injury : a methodological approach

Abstract : The aim of this work was to report a comprehensive literature review comparing the different methods and techniques of measurement of the posterior tibial slope (PTS) among the conventional radiograph, computed tomography (CT), and magnetic resonance imaging (MRI) in order to help the orthopedic surgeons to establish a standard and reliable measurement method. The work also includes two retrospective studies measuring the tibial slope using different modalities. It has been reported that the PTS has an influence on the kinematics of the knee notably the anterior cruciate ligament (ACL). A better understanding of the significance of the PTS could improve the development of ACL injury screening and prevention programmes, and might serve as a basis for individual adapted rehabilitation programmes after ACL reconstruction. Additionally, in several orthopedic interventions such as high tibial osteotomy, the tibial slope can result in altered knee mechanics. Therefore, an exact preoperative measurement of the posterior tibial slope is mandatory. Several methods are used on conventional radiographs, CT and MRI, but until now there is no standard validated method. The first part of this work was a general introduction about the anatomical structures of interest involved in this study, namely the knee joint, the anterior cruciate ligaments, the menisci, and the tibia, this introduction part included the gross anatomy, the microscopic structure, function, and some clinical considerations. The second part of the work is dedicated to a systematic review of the available modalities and techniques in the literature. Information regarding methods of measurement of the tibial slope in normal and ACL-injury subjects was extracted from all the studies in a systematic fashion and classified according to the measurement technique and used modalities. The most common used axis was the proximal tibial anatomical axis (PTAA), and the midpoint method is the most frequently used method for calculating the PTAA. By direct comparison, the greatest value of the medial tibial slope (MTS) for the pathological knee was achieved by the radiological studies, while the MRI studies presented the smallest values. Consequently, for the pathological lateral tibial slope (LTS), the MRI values were smaller than that of the CT studies. The greatest values of the MTS and LTS were obtained by the anterior tibial cortex axis, while the minimum values were achieved by the tibial diaphyseal axis.This third part of the work was a case-control study, by using MRI, the bony slopes as well as the lateral and medial meniscal slopes (LMS, MMS) were compared in 100 patients with isolated ACL injury and a control group of 100 patients with patello-femoral pain and an intact ACL. The most important finding of this study is that the increased tibial slopes, both bony and meniscal, are risk factors for ACL injury. As the meniscus tends to correct the observed slope towards the horizontal, loss of the posterior meniscus may potentiate this effect by increasing the functional slope. The fourth part of the work is aimed to evaluate the effects of the patient characteristics, time from injury (TFI), and PTS on meniscal tear patterns. In the 362 ACL-injured analyzed patients; the most common tear location was the posterior horn (PH) of the medial meniscus (MM), followed by tear involving the whole MM. Patient age, BMI, and TFI were significantly associated with the incidence of MM tear. An increase in the tibial slope, especially of the lateral plateau, seems to increase the risk of tear of the lateral meniscus (LM), and of both menisci
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Ashraf Elmansori. The effect of the increased posterior tibial slope on the integrity of the anterior cruciate ligament and patterns of the meniscal injury : a methodological approach. Surgery. Université de Lyon, 2019. English. ⟨NNT : 2019LYSE1062⟩. ⟨tel-02268223⟩

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