Pivot Shift Test

Kanamori A, Woo SL, Ma CB, Zeminski J, Rudy TW, Li G, Livesay GA (2000) The forces in the anterior cruciate ligament and knee kinematics during a simulated pivot shift test a human cadaveric study using robotic technology. Arthroscopy 16 633-639... 

Markolf KL, Park S, Jackson SR, McAllister DR (2008) Simulated pivot-shift testing with single and double bundle anterior cruciate ligament reconstructions. J Bone Joint Surg Am 90 1681-1689... 

Abstract Anterior cruciate ligament (ACL) injury is one of the most common knee traumas, particularly during sport activities. Giving way is a subjective symptom of the knee with ACL insufficiency. A number of clinical tests for ACL laxity have been proposed since it was first described by Stark in 1850. To quantitatively evaluate knee laxity, several knee ligament measurement devices have been also developed. The results of the manual tests and quantitative measurement are described in a grading system for further clinical evaluations, most commonly using the IKDC (International Knee Documentation Committee) evaluation form. Recently the importance of pivot-shift test as a detector of a dynamic rotational instability has been reported. In recent years, with new technologies, dynamic three-dimensional knee instability measurement devices also have been developed. 

The pivot-shift phenomenon [9, 31], which consists of a tibial anterior dislocation and a subsequent reduction of lateral compartment of the knee joint, is a dynamic instability [3, 9]. Losee reported the pivot-shift test in which the hip was abducted and the knee was passively flexed from full extension with internal tibial torque, axial load, and valgus stress applied manually to induce the pivot-shift phenomenon (Eig. 11.3) [3]. The pivot-shift test is usually positive in ACL-deficient knees but sometimes positive in ACL-reconstructed knees in which anterior stability has been successfully restored. The pivot-shift test has been reported to be associated with subjective symptoms and knee functions [32] therefore, this test has been considered as an important test to assess knee stability. The grade of the pivot-shift phenomenon can be graded by the examiner subjectively as none (—), glide (+), clunk (++), or gross (+++) according to the International Knee Documentatimi Committee (IKDC) form (Table 11.2) [33]. 

Kuroda et al. examined the similarities and differences in the pivot-shift test among international orthopedic surgeons using questionnaires and reported the... 

Fig. 11.3 The pivot-shift test the hip was abducted and the knee was passively flexed fi-om full extension with internal tibial toque, axial load, and valgus stress applied manually to induce the pivot-shift phenomenon...

Table 11.2 Pivot-shift test and its clinical grades...

The pivot-shift test [3,9] is commonly performed in a clinical setting [33], and it has been reported to be associated with subjective symptoms and knee functions [32]. Therefore, the pivot-shift test could detect abnormal knee kinematics and is a convenient test in the evaluation of results of ACL reconstructions. As mentioned in the previous section, the results of the manual tests are often described in a grading system for further clinical comparisons, most commonly using the IKDC evaluation form [39]. However, the clinical evaluation of the manual tests is subjectively determined by the examiners hands due to the lack of objective measurement systems resulting in inconsistency across examiners [40]. 

Some objective measurement systems have been developed and used in research and clinical practice to monitor the three-dimensional (3D) position displacement of the tibial dislocation during the pivot-shift test [40-42]. However, the measurement of the 3D position displacement in those research can be regarded as a static measurement that is assumed to be insufficient to quantify the dynamic instability and to have little relationship to subjective knee functions [32, 43]. Therefore, to quantitatively evaluate dynamic instability such as pivot-shift test in ACL-deficient and ACL-reconstructed knees is crucial for more accurately assessing clinical results after ACL reconstruction. 

Several objective measurement parameters have been introduced to monitor the 3D position displacement of the tibia in relation to the femur during the pivot-shift test [40, 42]. It has been suggested that a more dynamic parameter, such as 3D acceleration, should represent the dynamism of the pivot-shift phenomenon and can be more related to the dynamic rotatory knee laxity [21, 44—48]. 3D-kinematic assessments of the pivot-shift phenomenon have been attempted in in vitro studies [42, 49-51] and in intraoperatively using a sensor measurement system [41]. However, those measurement systems cannot be utilized in current clinical setting due to the invasiveness and/or the obstmctiveness to the pivot-shift testing maneuver. 

Katz JW, Fingeroth RJ (1986) The diagnostic accuracy of ruptures of the anterior cruciate ligament comparing the lachman test, the anterior drawer sign, and the pivot shift test in acute and chronic knee injuries. Am J Sports Med 14 88-91... 

Kim SJ, Kim HK (1995) Reliability of the anterior drawer test, the pivot shift test, and the lachman test. Clin Orthop Relat Res 317 237-242... 

Hoshino Y, Kuroda R, Nagamune K, Yagi M, Mizuno K, Yamaguchi M, Muratsu H, Yoshiya S, Kurosaka M (2007) In vivo measurement of the pivot-shift test in the anterior cruciate ligament-deficient knee using an electromagnetic device. Am J Sports Med 35 1098-1104... 

Kondo et al. [4] reported a unique laboratory study to verify biomechanical effects of this ACL reconstruction procedure. Namely, they arthroscopically performed this anatomic double-bundle reconstruction procedure and the conventional single-bundle reconstruction procedure with cadaver knees and biomechan-ically compared the knee stability among the two procedures and the normal knee, under the following loading conditions 90-N anterior tibial force, 5-Nm internal and external tibial torques, and a simulated pivot-shift test. In the results, there were significant reductions of anterior laxity of 3.5 mm and internal rotational laxity of... 

In 2006, Yasuda et al. [2] reported the first prospective comparative study to evaluate this anatomic double-bundle procedure using 72 patients. Concerning the side-to-side anterior laxity and the pivot-shift test, the anatomic double-bundle group was... 

Study The mean side-to-side difference in instrumented knee-laxity testing (anterior displacement of tibia) Pivot shift test (positive rate) Other findings Complications... 

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