The Pivot Shift: Current Experimental Methodology and Clinical Utility for Anterior Cruciate Ligament Rupture and Associated Injury

Vaudreuil, Nicholas J.; Rothrauff, Benjamin B.; de, Darren; Musahl, Volker

doi:10.1007/s12178-019-09529-7

Cited by 35 publications

(41 citation statements)

References 70 publications

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“…The pivot-shift test is the most specific physical examination test for the diagnosis of anterior cruciate ligament (ACL) injuries. 2,23,33,34,40 The pivot shift is a cornerstone of knee laxity assessment because it is an important preoperative predictor of clinical outcomes, serves to guide an appropriated index of suspicion for injury to the secondary restraints, and is the primary outcome measure that quantifies improvement in knee stability after ACL reconstruction. 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.…”

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confidence: 99%

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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confidence: 99%

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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“…After identi cation of the structure, a histological and radiological MRI study was initiated (AOL visualized in x examined specimens). The authors studied the anatomy and biomechanics of the region 5,8,9,10,16,17,18,19,21,22 and developed a reasoning termed the Theory of Tibial Quadrants, which facilitates the understanding of circumferential joint structures and rotational control (Figure 4). The tibial surface is divided into an anterior and posterior portion through a band that connects the femoral transepicondylar plane, the origin or near origin of the important ligaments that travel toward the tibia.…”

Section: Discussionmentioning

confidence: 99%

The Anterior Oblique Ligament description in the knee anteromedial compartment

Jorge¹,

Oliveira²,

Resende³

et al. 2020

Preprint

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Purpose: To describe a ligamentous structure in the anteromedial region of the knee identified in a series of anatomical dissections of cadaveric specimens.Methods: Sixteen cadaveric knees were dissected to study the medial compartment. Exclusion criteria were signs of trauma, previous surgery, signs of osteoarthritis and poor preservation state. The main structures of this region were identified during medial dissection. After releasing the superficial medial collateral ligament (sMCL) of the tibia, the Anterior Oblique Ligament (AOL), was isolated. The morphology of the structure and its relationship with known anatomical parameters were determined. For the statistical analysis, the means and standard deviations were calculated for continuous variables. A 95% confidence intervals was defined as significant. Student's t-tests were used for continuous variables.Results: After dissection a distinct ligamentous structure (AOL) was found in the medial region of the knee. This structure was found in 100% of the cases, was located extracapsularly and originated in the anterior aspect of the medial epicondyle, running obliquely toward the tibia. When crossing the joint, the ligament presented a fan-shaped opening, exhibiting a larger area at the tibial insertion. The AOL had a mean thickness of 6.83±1.34 mm at its femoral origin and 13.06±1.91 at its tibial insertion. It had a significantly (p = 0.0009) longer mean length with the knee at 90° of flexion (33.82±9.50 mm) than with the knee in total extension (26.56±9.48 mm), indicating that the ligament is tensioned in flexion.Conclusion: A structure was identified in the anteromedial compartment of the knee with a ligamentous appearance originating in the medial femoral epicondyle and with tibial insertion anterior to the sMCL. Clinical relevance: This study demonstrates the anatomy of a new medial structure of the knee. As a result, there will be a better understanding of the stability of the knee.

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“…Additionally, following ACL injury, the iliotibial band is the primary restraint to tibial internal rotation during a simulated pivot shift [24]. Similar biomechanical studies have found that the ALC experiences the highest in situ forces and resists rotatory knee instability at 90°of flexion and insignificant in situ force at 30°of flexion where rotatory knee instability is normally assessed [4,60].…”

Section: Biomechanics Of the Alc And Residual Rotatory Knee Instabilitymentioning

confidence: 91%

Anterior Cruciate Ligament Injury and the Anterolateral Complex of the Knee—Importance in Rotatory Knee Instability?

Golan

Tisherman

Byrne

et al. 2019

Curr Rev Musculoskelet Med

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Purpose of Review In the setting of rotatory knee instability following anterior cruciate ligament (ACL) reconstruction, there has been a resurgence of interest in knee's anterolateral complex (ALC). Reconstruction or augmentation of the ALC with procedures such as a lateral extra-articular tenodesis (LET) has been proposed to reduce rotatory knee instability in conjunction with ACL reconstruction. The current review investigates the recent literature surrounding the role of the ALC in preventing rotatory knee instability. Recent Findings The knee's anterolateral complex (ALC) is a complex structure composed of the superficial and deep portions of the iliotibial band, the capsulo-osseous layer, and the anterolateral capsule. Distally, these various layers merge to form a single functional unit which imparts stability to the lateral knee. While the iliotibial band and the capsule-osseous layer have been shown to be primary restraints to rotatory motion after ACL injury, the biomechanical role of the anterolateral capsule remains unclear. Biomechanical studies have shown that the anterolateral capsule and the anterolateral thickening of this capsule act as a sheet of fibrous tissue which does not resist motion around the knee as other longitudinally oriented ligaments do. Summary Augmentation of the ALC, with LET, has been performed globally for over 30 years. This procedure can decrease rotatory knee instability, but long-term studies have found little difference in patient-reported outcomes, osteoarthritis, or ACL reconstruction failure with the addition of LET. Further research is needed to clarify indications for the clinical use of ALC-based procedures.

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The Pivot Shift: Current Experimental Methodology and Clinical Utility for Anterior Cruciate Ligament Rupture and Associated Injury

Cited by 35 publications

References 70 publications

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

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

The Anterior Oblique Ligament description in the knee anteromedial compartment

Anterior Cruciate Ligament Injury and the Anterolateral Complex of the Knee—Importance in Rotatory Knee Instability?

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