Risk factors for residual pivot shift after anterior cruciate ligament reconstruction: data from the MAKS group

Ueki, Hiroko; Nakagawa, Yusuke; Ohara, Toshiyuki; Watanabe, Toshifumi; Horie, Masafumi; Katagiri, Hiroki; Otabe, Koji; Katagiri, Kenta; Kanehiro, Hiromichi; Katakura, Mai; Hoshino, Takashi; Inomata, Kei; Araya, Naoko; Sekiya, Ichiro; Muneta, Takeshi; Koga, Hideyuki

doi:10.1007/s00167-018-5005-4

Cited by 53 publications

(53 citation statements)

References 35 publications

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“…10-12 Improved control of internal tibial rotation by additional extra-articular tenodesis or ALL reconstruction could protect the ACL graft from excessive stress during the postoperative period and return to sports. 6,10,41,53,54,58…”

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confidence: 99%

Clinical Outcomes of Isolated Revision Anterior Cruciate Ligament Reconstruction or in Combination With Anatomic Anterolateral Ligament Reconstruction

et al. 2019

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Background: Although the cause of rotational instability after revision anterior cruciate ligament reconstruction (ACLR) is multifactorial, the rationale of adding an extra-articular procedure is based on its ability to restrict rotational instability. Purpose: To assess the effect of anterolateral ligament (ALL) reconstruction on revision ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 87 patients who underwent revision ACLR between March 2011 and July 2014 with a follow-up of more than 3 years were included in this retrospective study. Patients were divided into the isolated revision ACLR group (group I, n = 45, from March 2011 to January 2013) or the revision ACLR in combination with ALL reconstruction group (group C, n = 42, from February 2013 to July 2014). Subjective knee assessments including the subjective International Knee Documentation Committee (IKDC) form, Lysholm score, Tegner activity scale, and Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) scale were used. Clinical and functional tests were performed before surgery and at ≥6 months after surgery. All tests were usually completed at 36 months of follow-up. Results: The mean follow-up duration for groups I and C were 41.5 ± 8.2 and 38.2 ± 6.9 months, respectively ( P = .451). The subjective IKDC score, Tegner score, and ACL-RSI score were significantly better in group C compared with those in group I at the last follow-up (84.3 ± 18.5 vs 75.9 ± 19.2, 7.0 ± 0.8 vs 6.3 ± 0.7, and 69.5 ± 25.4 vs 51.9 ± 23.1, respectively), although they were not significantly different between the 2 groups at 12 months after surgery (79.2 ± 18.8 vs 76.7 ± 17.2, 6.7 ± 0.7 vs 6.5 ± 0.9, and 50.2 ± 24.6 vs 49.9 ± 25.1, respectively). There were no significant differences in KT-2000 arthrometer, isokinetic extensor strength, single-legged hop for distance, co-contraction test, or carioca test results between the 2 groups at the last follow-up ( P = .304, .068, .125, .056, and .066, respectively). Preoperatively, 43 (95.6%) patients in group I and 40 (95.2%) patients in group C had a grade 2 or 3 pivot shift ( P = .387). Postoperatively, 23 (53.5%) patients in group I and 38 (90.5%) patients in group C had a negative pivot shift ( P < .001). Group C showed a higher rate of return to the same level of sports activity than group I (57.1% vs 25.6%, respectively; P = .008), although there was no significant difference in the rate of return to any sports activity at the last follow-up (88.4% in group I vs 88.1% in group C; P = .713). Conclusion: Revision ACLR in combination with ALL reconstruction significantly reduced rotational laxity and showed a higher rate of return to the same level of sports activity than revision ACLR alone, although there were no significant differences in anterior laxity or functional test results between the 2 groups.

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Clinical Outcomes of Isolated Revision Anterior Cruciate Ligament Reconstruction or in Combination With Anatomic Anterolateral Ligament Reconstruction

et al. 2019

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“…The presence of a high-grade preoperative pivot shift is associated with an increased risk of rerupture after ACL reconstruction and an increased risk of persistent rotatory instability after surgery as compared with a low-grade pivot shift. 11,34,37 Owing to increased knee rotational instability, patients with a grade 3 pivot shift experience poorer clinical outcomes.…”

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Risk Factors for Grade 3 Pivot Shift in Knees With Acute Anterior Cruciate Ligament Injuries: A Comprehensive Evaluation of the Importance of Osseous and Soft Tissue Parameters From the SANTI Study Group

et al. 2020

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Background: Preoperative grade 3 pivot shift has been reported to be associated with higher rates of anterior cruciate ligament (ACL) failure, persistent instability, and inferior patient-reported outcomes. The etiology of a high-grade pivot shift is multifactorial, and numerous factors have been suggested to be responsible. More attention has recently been focused on injury to the anterolateral structures (ALS) as a risk factor for a grade 3 pivot shift. Purpose: To determine risk factors for grade 3 pivot shift, including soft tissue and osseous parameters. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A prospective evaluation was undertaken of 200 consecutive patients undergoing acute ACL reconstruction (within 10 days of injury). An open exploration of the lateral side of the injured knee was performed at the time of the index procedure. Details regarding patient and injury characteristics were recorded, as were details of soft tissue injuries, including meniscal tears, ALS lesions, medial collateral ligament tears, and chondral injuries. Osseous parameters (tibial slope and condylar ratios) were determined per established magnetic resonance imaging protocols. A multivariate logistic regression with penalized maximum likelihood was used to identify risk factors associated with International Knee Documentation Committee (IKDC) grade 3 pivot shift. Results: The mean ± SD age of the population was 28.3 ± 9.8 years; 67.5% of patients were male. Among patients, 35 (17.5%) had a high-grade pivot shift (IKDC grade 3), and 165 (82.5%) had a low-grade pivot shift (IKDC grades 1 and 2). Univariate and multivariate logistic regression analysis demonstrated that injury to the ALS was the only significant risk factor for grade 3 pivot shift (odds ratio, 13.49; 95% CI, 1.80-1725.53). Conclusion: This comprehensive evaluation of soft tissue and osseous factors has identified that injury to the ALS is the most important risk factor for grade 3 pivot shift in acute ACL-injured knees.

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“…Several studies have investigated the risk factors for residual instability after ACLR. Ueki et al 31 reported that knee hyperextension and greater preoperative pivot shift under anesthesia were risk factors for residual pivot shift, as evaluated by subjective grading at 1 year postoperatively. Yamamoto et al 35 investigated the relationship between preoperative knee laxity as measured by posterior tibial reduction during the pivot shift using a navigation system and postoperative pivot shift as evaluated by subjective grading at 2-year follow-up.…”

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confidence: 99%

“… 6 , 13 Several studies on knee instability have indicated that high-grade pivot shift and knee hyperextension preoperatively are risk factors for postoperative residual instability. 31 With respect to rotation at 30° and 90° of flexion (ie, rotational laxity), a considerable effect of initial knee laxity on postoperative outcomes has been reported. 26 …”

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Preoperative Knee Instability Affects Residual Instability as Evaluated by Quantitative Pivot-Shift Measurements During Double-Bundle ACL Reconstruction

Kawanishi

Nozaki

Kobayashi

et al. 2020

Orthopaedic Journal of Sports Medicine

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Background: The pivot-shift test is an important indicator of functional outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR). Preoperative instability as indicated by the pivot-shift test is associated with residual instability after ACLR. Few studies have used quantitative means to evaluate the pivot shift after ACLR. Purpose: To investigate the relationship between preoperative and residual instability and to identify the risk factors for residual instability by using quantitative measurements of the pivot shift. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 91 patients undergoing primary double-bundle ACLR were retrospectively enrolled. Quantitative measurements of instability for ACL-deficient knees (ACLD) and uninjured contralateral knees (intact) preoperatively, as well as ACLR knees intraoperatively, were performed under general anesthesia using the pivot-shift test, with inertial sensors to measure acceleration and external rotational (ER) angular velocity. The ratios of intact to ACLD (ACLD/I) and intact to ACLR (ACLR/I) were measured. Patients who showed an ACLR/I of >1 were classified into the residual instability group, and those with an ACLR/I of ≤1 were classified into the noninstability group. Regarding demographic, surgical, and quantitative measurement factors, between-group comparisons and multivariate logistic regression were conducted for predictors of residual instability. Receiver operating characteristic curves were used to evaluate the correlations between ACLD/I and ACLR/I and the cutoff value of ACLD/I in predicting residual instability. Results: The predictive factors for intraoperative residual instability included female sex (odds ratio [OR], 0.3 [95% CI, 0.1-0.9]; P = .034) and ACLD/I for acceleration (OR, 1.6 [95% CI, 1.2-2.1]; P < .001), and ACLD/I for ER angular velocity (OR, 1.9 [95% CI, 1.2-3.1]; P = .013). Correlations between ACLD/I and ACLR/I were moderate with respect to both acceleration ( r = 0.435; P < .001) and ER angular velocity ( r = 0.533; P < .001). The cutoff points for ACLD/I were 4.9 for acceleration (sensitivity, 65.1%; specificity, 85.7%; area under the curve [AUC], 0.76) and 2.4 for ER angular velocity (sensitivity, 80.0%; specificity, 50.0%; AUC, 0.74). Conclusion: Greater preoperative instability was a risk factor for residual instability as measured intraoperatively by a quantitatively evaluation in the pivot shift during ACL reconstruction. Quantitative measurements of instability during the pivot shift mechanism under general anesthesia may enable surgeons to predict postoperative residual instability.

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Risk factors for residual pivot shift after anterior cruciate ligament reconstruction: data from the MAKS group

Abstract: II.

Cited by 53 publications

References 35 publications

Clinical Outcomes of Isolated Revision Anterior Cruciate Ligament Reconstruction or in Combination With Anatomic Anterolateral Ligament Reconstruction

Clinical Outcomes of Isolated Revision Anterior Cruciate Ligament Reconstruction or in Combination With Anatomic Anterolateral Ligament Reconstruction

Risk Factors for Grade 3 Pivot Shift in Knees With Acute Anterior Cruciate Ligament Injuries: A Comprehensive Evaluation of the Importance of Osseous and Soft Tissue Parameters From the SANTI Study Group

Preoperative Knee Instability Affects Residual Instability as Evaluated by Quantitative Pivot-Shift Measurements During Double-Bundle ACL Reconstruction

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