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Mayr HO, Rosenstiel N, Prakash KS, Comella LM, Woias P, Schmal H, Seidenstuecker M. Digital measurement of anterolateral knee laxity using strain sensors. Arch Orthop Trauma Surg 2023; 143:6719-6729. [PMID: 37592159 PMCID: PMC10542724 DOI: 10.1007/s00402-023-05024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 08/04/2023] [Indexed: 08/19/2023]
Abstract
PURPOSE The ambition of the research group was to develop a sensor-based system that allowed the transfer of results with strain sensors applied to the knee joint. This system was to be validated in comparison to the current static mechanical measurement system. For this purpose, the internal rotation laxity of the knee joint was measured, as it is relevant for anterolateral knee laxity and anterior cruciate ligament (ACL) injury. METHODS This is a noninvasive measurement method using strain sensors which are applied to the skin in the course of the anterolateral ligament. The subjects were placed in supine position. First the left and then the right leg were clinically examined sequentially and documented by means of an examination form. 11 subjects aged 21 to 45 years, 5 women and 6 men were examined. Internal rotation of the lower leg was performed with a torque of 2 Nm at a knee flexion angle of 30°. RESULTS Comparison of correlation between length change and internal knee rotation angle showed a strong positive correlation (r = 1, p < 0.01). Whereas females showed a significant higher laxity vs. males (p = 0.003). CONCLUSIONS The present study showed that the capacitive strain sensors can be used for reproducible measurement of anterolateral knee laxity. In contrast to the previous static systems, a dynamic measurement will be possible by this method in the future.
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Affiliation(s)
- Hermann O Mayr
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine, Medical Center-University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany.
| | - Nikolaus Rosenstiel
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine, Medical Center-University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Karthika S Prakash
- Department of Microsystems Engineering IMTEK, Albert-Ludwigs-University of Freiburg, Georges-Koehler-Allee 103, 79110, Freiburg, Germany
| | - Laura M Comella
- Department of Microsystems Engineering IMTEK, Albert-Ludwigs-University of Freiburg, Georges-Koehler-Allee 103, 79110, Freiburg, Germany
| | - Peter Woias
- Department of Microsystems Engineering IMTEK, Albert-Ludwigs-University of Freiburg, Georges-Koehler-Allee 103, 79110, Freiburg, Germany
| | - Hagen Schmal
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine, Medical Center-University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Michael Seidenstuecker
- G.E.R.N. Center of Tissue Replacement, Regeneration & Neogenesis, Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center-University of Freiburg, Albert-Ludwigs-University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
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Kim SH, Park YB, Ham DW, Lim JW, Lee HJ. Stress radiography at 30° of knee flexion is a reliable evaluation tool for high-grade rotatory laxity in complete ACL-injured knees. Knee Surg Sports Traumatol Arthrosc 2020; 28:2233-2244. [PMID: 31784781 DOI: 10.1007/s00167-019-05803-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 11/12/2019] [Indexed: 01/25/2023]
Abstract
PURPOSE To evaluate the diagnostic value of stress radiography and determine the cutoff values for high-grade anterolateral rotatory laxity in complete anterior cruciate ligament (ACL)-deficient knees at different positions. METHODS Forty-two patients with complete ACL rupture (group 1) and 37 normal subjects (group 2) were prospectively enrolled. The amount of anterior translation in the medial (MM) and lateral (LL) distance compartments and the difference between them (LL-MM distance) were measured using stress radiography at 30°, 45°, 60°, and 90° positions. The area under the receiver operating characteristic curve (AUC) was assessed for the presence of a high-grade (grade > 2) pivot shift. RESULTS The MM and LL distances in group 1 were significantly different at 30° and 45° positions (P < 0.05). The AUC of the MM (AUC, 0.903) and LL (AUC, 0.901) distances at the 30° position was significantly higher than that of the other positions (P = 0.000); however, the cutoff values were different to diagnose ACL injury (MM vs. LL, 3.1 mm vs. 5.4 mm). A 2.1-mm cutoff for the LL-MM distance showed 78.4% sensitivity and 90.3% specificity for detecting the presence of a high-grade pivot shift (AUC = 0.905, P = 0.000). CONCLUSION The cutoff values of stress radiography differed according to anatomical references and knee flexion positions. Stress radiography of a 2.1 mm difference in LL-MM distance at 30° of knee flexion can be a reliable method for high-grade rotatory laxity in complete ACL-injured knees. LEVEL OF EVIDENCE Level 1, diagnostic study.
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Affiliation(s)
- Seong Hwan Kim
- Department of Orthopedic Surgery, Hyundae General Hospital, Chung-Ang University College of Medicine, 21, Bonghyeon-ro, Jinjeop-eup, Namyangju-si, Gyeonggi-do, 12013, South Korea
| | - Yong-Beom Park
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea.
| | - Dae-Woong Ham
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea
| | - Jung-Won Lim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea
| | - Han-Jun Lee
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea
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Anterolateral ligament reconstruction as an augmented procedure for double-bundle anterior cruciate ligament reconstruction restores rotational stability: Quantitative evaluation of the pivot shift test using an inertial sensor. Knee 2020; 27:397-405. [PMID: 32178972 DOI: 10.1016/j.knee.2020.02.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/01/2020] [Accepted: 02/09/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to investigate the biomechanical function of the anterolateral structures (ALS) of the knee regarding rotational stability, and to attempt to verify the effectiveness of anterolateral ligament (ALL) reconstruction concomitant with double-bundle anterior cruciate ligament (ACL) reconstruction by quantifying the pivot shift test (PST) using an inertial sensor. METHODS Six knees of the fresh-frozen cadavers were evaluated during the following phases: (1) [Intact]; (2) ACL-deficient [ACL-D]; (3) ACL-reconstructed [ACL-R]; (4) ACL-reconstructed + ALS-deficient [ACL-R + ALS-D]; and (5) combined ACL and ALL reconstructed [ACL-R + ALL-R]. We evaluated knee rotational instability during each phase using the PST. We used an inertial sensor to calculate tibial external rotational angular velocity (ERAV) and tibial acceleration. Data were analyzed using repeated-measures analysis of variance; statistical significance was accepted as P < 0.05. RESULTS Relative to [Intact], [ACL-D] caused a significant increase in ERAV and acceleration. However, there was no difference in these parameters between [ACL-R] and [Intact]. [ACL-R + ALS-D] increased ERAV significantly compared with [ACL-R], and there was a significant difference between ERAV during [ACL-R + ALS-D] and [Intact]. However, ERAV was significantly reduced during [ACL-R + ALL-R] compared with [ACL-R + ALS-D], and there was no significant difference in ERAV or acceleration between [ACL-R + ALL-R] and [Intact]. CONCLUSIONS ALS controlled rotational instability in cooperation with the ACL in a cadaveric model. In cases of combined injury of ACL and ALS, concomitant ACL and ALL reconstruction may restore knee stability comparable with the intact state.
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Triaxial accelerometer evaluation is correlated with IKDC grade of pivot shift. Knee Surg Sports Traumatol Arthrosc 2020; 28:381-388. [PMID: 31201443 DOI: 10.1007/s00167-019-05563-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 06/07/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the correlation between tibial acceleration parameters measured by the KiRA device and the clinical grade of pivot shift. The secondary objective was to report the risk factors for pre-operative high-grade pivot shift. METHODS Two-hundred and ninety-five ACL deficient patients were examined under anesthesia. The pivot shift tests were performed twice by an expert surgeon. Clinical grading was performed using the International Knee Documentation Committee (IKDC) scale and tibial acceleration data was recorded using a triaxial accelerometer system (KiRA). The difference in the tibial acceleration range between injured and contralateral limbs was used in the analysis. Correlation coefficients were calculated using linear regression. Multivariate logistic regression was used to identify risk factors for high grade pivot shift. RESULTS The clinical grade of pivot shift and the side-to-side difference in delta tibial acceleration determined by KiRA were significantly correlated (r = 0.57; 95% CI 0.513-0.658, p < 0.0001). The only risk factor identified to have a significant association with high grade pivot shift was an antero-posterior side to side laxity difference > 6 mm (OR = 2.070; 95% CI (1.259-3.405), p = 0.0042). CONCLUSION Side-to-side difference in tibial acceleration range, as measured by KiRA, is correlated with the IKDC pivot shift grade in anaesthetized patients. Side-to-side A-P laxity difference greater than 6 mm is reported as a newly defined risk factor for high grade pivot shift in the ACL injured knee. DIAGNOSTIC STUDY Level II.
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Risk factors for residual anterolateral rotational instability after double bundle anterior cruciate ligament reconstruction: Evaluation by quantitative assessment of the pivot shift phenomenon using triaxial accelerometer. Knee 2020; 27:95-101. [PMID: 31672497 DOI: 10.1016/j.knee.2019.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/18/2019] [Accepted: 09/27/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Exact knowledge of risk factors for residual anterolateral rotatinoal instability (ALRI) after anterior cruciate ligament (ACL) reconstruction is limited. The purpose of this study was to analyse possible risk factors for ALRI after ACL reconstruction. METHODS Quantitative assessment of the pivot shift phenomenon by measuring tibial acceleration was performed in 46 patients during primary double-bundle ACL reconstructions. The absolute value of the acceleration of the injured knee after provisional fixation of the ACL grafts ('absolute residual acceleration') and the subtraction of the acceleration of the uninjured knee from absolute residual acceleration ('relative residual acceleration') were defined as indicators for residual ALRI. The associations between these indicators and nine candidate risk factors were analysed using univariate and multiple regression analyses. RESULTS Multiple regression analysis revealed that absolute residual acceleration was positively associated with both preoperative acceleration difference between injured and uninjured knees (β = 0.469, P < 0.001) and tibial acceleration of the uninjured knee (β = 0.597, P < 0.001). Relative residual acceleration was also positively associated with preoperative acceleration difference between injured and uninjured knees (β = 0.446, P< 0.001), but was negatively associated with tibial acceleration of the uninjured knee (β = -0.763, P < 0.001). CONCLUSIONS Patients with larger preoperative side-to-side difference of the pivot shift phenomenon have higher risk for both absolute and relative residual ALRIs after ACL reconstruction, whereas patients with larger pivot shift phenomenon in their uninjured knees are at higher risk for absolute residual ALRI but not for relative residual ALRI.
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Hughes JD, Rauer T, Gibbs CM, Musahl V. Diagnosis and treatment of rotatory knee instability. J Exp Orthop 2019; 6:48. [PMID: 31865518 PMCID: PMC6925612 DOI: 10.1186/s40634-019-0217-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/13/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Rotatory knee instability is an abnormal, complex three-dimensional motion that can involve pathology of the anteromedial, anterolateral, posteromedial, and posterolateral ligaments, bony alignment, and menisci. To understand the abnormal joint kinematics in rotatory knee instability, a review of the anatomical structures and their graded role in maintaining rotational stability, the importance of concomitant pathologies, as well as the different components of the knee rotation motion will be presented. MAIN BODY The most common instability pattern, anterolateral rotatory knee instability in an anterior cruciate ligament (ACL)-deficient patient, will be discussed in detail. Although intra-articular ACL reconstruction is the gold standard treatment for ACL injury in physically active patients, in some cases current techniques may fail to restore native knee rotatory stability. The wide range of diagnostic options for rotatory knee instability including manual testing, different imaging modalities, static and dynamic measurement, and navigation is outlined. As numerous techniques of extra-articular tenodesis procedures have been described, performed in conjunction with ACL reconstruction, to restore anterolateral knee rotatory stability, a few of these techniques will be described in detail, and discuss the literature concerning their outcome. CONCLUSION In summary, the essence of reducing anterolateral rotatory knee instability begins and ends with a well-done, anatomic ACL reconstruction, which may be performed with consideration of extra-articular tenodesis in a select group of patients.
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Affiliation(s)
- Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA, 15203, USA
| | - Thomas Rauer
- Department of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Christopher M Gibbs
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA, 15203, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA, 15203, USA.
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Lee JCY, Yung PSH, Lam MH, Hung ASL, Fong DTP, Chan WY, Chan KM. A non-invasive biomechanical device to quantify knee rotational laxity: Verification of the device in human cadaveric specimens. Asia Pac J Sports Med Arthrosc Rehabil Technol 2019; 16:19-23. [PMID: 30984559 PMCID: PMC6445399 DOI: 10.1016/j.asmart.2018.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 11/02/2018] [Accepted: 11/21/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Biomechanical measurement tools have been developed and widely used to precisely quantify knee anterior-posterior laxity after anterior cruciate ligament (ACL) injury. However, validated objective device to document knee rotational laxity, though being developed by different researchers, are not yet widely used in the daily clinical practice. A new biomechanical device was developed to quantify knee internal and external rotations. METHODS The reliability of the new biomechanical device which measures knee rotations were tested. Different torques (1-10Nm) were applied by the device to internally and externally rotate human cadaveric knees, which were held in a flexion angle of 30°. The rotations were measured by the device in degrees. There were two independent testers, and each tester carried out three trials. Intra-rater and inter-rater reliability were quantified in terms of intraclass correlation (ICC) coefficient among trials and between testers. The device was verified by the comparison with a computer assisted navigation system. ICC was measured. Mean, standard deviation and 95% confident interval of the difference as well as the root mean square difference were calculated. The correlations were deemed to be reliable if the ICC was above 0.75. RESULTS The intra-rater and inter-rater reliability achieved high correlation for both internal and external rotation, ranged from 0.959 to 0.992. ICC between the proposed meter and the navigation system for both internal and external rotation was 0.78. The mean differences were 2.3° and 2.5° for internal and external rotation respectively. CONCLUSIONS A new knee rotational laxity meter was proposed in this study. Its reliability was verified by showing high correlation among trials. It also showed good correlation to a gold standard of measurement. It might be used to document knee rotational laxity for various purposes, especially after ACL injury, after further validation of the device in human subjects.
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Affiliation(s)
- Jeffrey Chun-Yin Lee
- Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Hong Kong, China
| | - Patrick Shu-Hang Yung
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
- The Hong Kong Jockey Club Sports Medicine and Health Sciences Centre, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Mak-Ham Lam
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
- The Hong Kong Jockey Club Sports Medicine and Health Sciences Centre, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Aaron See-Long Hung
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
- The Hong Kong Jockey Club Sports Medicine and Health Sciences Centre, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Daniel Tik-Pui Fong
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Wood Yee Chan
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Kai-Ming Chan
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
- The Hong Kong Jockey Club Sports Medicine and Health Sciences Centre, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Zaffagnini S, Signorelli C, Grassi A, Hoshino Y, Kuroda R, de Sa D, Sundemo D, Samuelsson K, Musahl V, Karlsson J, Sheean A, Burnham JM, Lian J, Smith C, Popchak A, Herbst E, Pfeiffer T, Araujo P, Oostdyk A, Guenther D, Ohashi B, Irrgang JJ, Fu FH, Nagamune K, Kurosaka M, Marcheggiani Muccioli GM, Lopomo N, Raggi F, Svantesson E, Hamrin Senorski E, Bjoernsson H, Ahlden M, Desai N. Anatomic Anterior Cruciate Ligament Reconstruction Using Hamstring Tendons Restores Quantitative Pivot Shift. Orthop J Sports Med 2018; 6:2325967118812364. [PMID: 30574514 PMCID: PMC6299314 DOI: 10.1177/2325967118812364] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: It is still uncertain how surgical reconstruction of the anterior cruciate
ligament (ACL) is able to restore rotatory laxity of the involved joint. The
desired amount of restraint applied by the ACL graft, as compared with the
healthy knee, has not been fully clarified. Purpose: To quantify the ability of single-bundle anatomic ACL reconstruction using
hamstring tendons in reducing the pivot-shift phenomenon immediately after
surgery under anesthesia. Study Design: Case series; Level of evidence, 4. Methods: An inertial sensor and image analysis were used at 4 international centers to
measure tibial acceleration and lateral compartment translation of the knee,
respectively. The standardized pivot-shift test was quantified in terms of
the side-to-side difference in laxity both preoperatively and
postoperatively with the patient under anesthesia. The reduction in both
tibial acceleration and lateral compartment translation after surgery and
the side-to-side difference were evaluated using the Wilcoxon signed-rank
test. Alpha was set at P < .05. Results: A total of 107 patients were recruited for the study, and data were available
for 89 patients. There was a statistically significant reduction in
quantitative rotatory knee laxity between preoperatively (inertial sensor,
2.55 ± 4.00 m/s2; image analysis, 2.04 ± 2.02 mm) and
postoperatively (inertial sensor, –0.54 ± 1.25 m/s2; image
analysis, –0.10 ± 1.04 mm) between the involved and healthy joints, as
measured by the 2 devices (P < .001 for both).
Postoperatively, both devices detected a lower rotatory laxity value in the
involved joint compared with the healthy joint (inertial sensor, 2.45 ± 0.89
vs 2.99 ± 1.10 m/s2, respectively [P < .001];
image analysis, 0.99 ± 0.83 vs 1.09 ± 0.92 mm, respectively
[P = .38]). Conclusion: The data from this study indicated a significant reduction in the pivot shift
when compared side to side. Both the inertial sensor and image analysis used
for the quantitative assessment of the pivot-shift test could successfully
detect restoration of the pivot shift after anatomic single-bundle ACL
reconstruction. Future research will examine how pivot-shift control is
maintained over time and correlation of the pivot shift with return to full
activity in patients with an ACL injury.
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Affiliation(s)
- Stefano Zaffagnini
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Cecilia Signorelli
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alberto Grassi
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Yuichi Hoshino
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Ryosuke Kuroda
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Darren de Sa
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - David Sundemo
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Kristian Samuelsson
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Volker Musahl
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Jon Karlsson
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Andrew Sheean
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Jeremy M Burnham
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Jayson Lian
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Clair Smith
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Adam Popchak
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Elmar Herbst
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Thomas Pfeiffer
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Paulo Araujo
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alicia Oostdyk
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Daniel Guenther
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Bruno Ohashi
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - James J Irrgang
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Freddie H Fu
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Kouki Nagamune
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Masahiro Kurosaka
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - Nicola Lopomo
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Federico Raggi
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Eleonor Svantesson
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - Haukur Bjoernsson
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Mattias Ahlden
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Neel Desai
- Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Anatomic double bundle ACL reconstruction outperforms any types of single bundle ACL reconstructions in controlling dynamic rotational laxity. Knee Surg Sports Traumatol Arthrosc 2018; 26:1414-1419. [PMID: 29138915 DOI: 10.1007/s00167-017-4781-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To compare the different types of ACL reconstructions in terms of knee dynamic laxity evaluated by acceleration. METHODS Sixteen fresh frozen cadaveric knees were used. Pivot shift test was manually performed while monitoring the tibial acceleration by use of a triaxial accelerometer. The test was repeated before and after the ACL resection and reconstruction. Three types of ACL reconstruction were tested: (1) Anatomic Single-Bundle reconstruction (n = 8), the graft was placed at the center of the ACL footprint for the both femoral and tibial sides (tunnel diameter: 8mm); (2) Conventional Single-Bundle reconstruction (n = 8), the graft was placed from the tibial PL footprint to femoral high AM position (tunnel diameter: 8mm) and (3) Anatomic Double-Bundle reconstruction (n = 8). The acceleration in each of three x-y-z directions and the overall magnitude of acceleration was calculated to evaluate dynamic rotational laxity and compared between different ACL reconstructions. RESULTS The overall magnitude of acceleration was significantly different between ACL intact and deficient knees (p < 0.0001). The acceleration was reduced by the DB ACL reconstruction to the intact level (n.s.), but the two SB ACL reconstruction failed to achieve the intact level of the acceleration (p = 0.0002non-anatomic SB, p < 0.0001 anatomic SB). CONCLUSION The anatomic DB reconstruction better restores dynamic rotational laxity when compared to the SB ACL reconstructions no matter if the tunnel placement was anatomic. The anatomic DB reconstruction better restores dynamic rotational laxity when compared to both anatomic and non-anatomic SB ACL reconstruction. For this reason anatomic DB ACL reconstruction is recommended for cases where rotational laxity is an issue.
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Kaiser JM, Vignos MF, Kijowski R, Baer G, Thelen DG. Effect of Loading on In Vivo Tibiofemoral and Patellofemoral Kinematics of Healthy and ACL-Reconstructed Knees. Am J Sports Med 2017; 45:3272-3279. [PMID: 28903010 PMCID: PMC5955618 DOI: 10.1177/0363546517724417] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although knees that have undergone anterior cruciate ligament reconstruction (ACLR) often exhibit normal laxity on clinical examination, abnormal kinematic patterns have been observed when the joint is dynamically loaded during whole body activity. This study investigated whether abnormal knee kinematics arise with loading under isolated dynamic movements. HYPOTHESIS Tibiofemoral and patellofemoral kinematics of ACLR knees will be similar to those of the contralateral uninjured control knee during passive flexion-extension, with bilateral differences emerging when an inertial load is applied. STUDY DESIGN Controlled laboratory study. METHODS The bilateral knees of 18 subjects who had undergone unilateral ACLR within the past 4 years were imaged by use of magnetic resonance imaging (MRI). Their knees were cyclically (0.5 Hz) flexed passively. Subjects then actively flexed and extended their knees against an inertial load that induced stretch-shortening quadriceps contractions, as seen during the load acceptance phase of gait. A dynamic, volumetric, MRI sequence was used to track tibiofemoral and patellofemoral kinematics through 6 degrees of freedom. A repeated-measures analysis of variance was used to compare secondary tibiofemoral and patellofemoral kinematics between ACLR and healthy contralateral knees during the passive and active extension phases of the cyclic motion. RESULTS Relative to the passive motion, inertial loading induced significant shifts in anterior and superior tibial translation, internal tibial rotation, and all patellofemoral degrees of freedom. As hypothesized, tibiofemoral and patellofemoral kinematics were bilaterally symmetric during the passive condition. However, inertial loading induced bilateral differences, with the ACLR knees exhibiting a significant shift toward external tibial rotation. A trend toward greater medial and anterior tibial translation was seen in the ACLR knees. CONCLUSION This study demonstrates that abnormal knee kinematic patterns in ACLR knees emerge during a simple, active knee flexion-extension task that can be performed in an MRI scanner. CLINICAL RELEVANCE It is hypothesized that abnormal knee kinematics may alter cartilage loading patterns and thereby contribute to increased risk for osteoarthritis. Recent advances in quantitative MRI can be used to detect early cartilage degeneration in ACLR knees. This study demonstrates the feasibility of identifying abnormal ACLR kinematics by use of dynamic MRI, supporting the combined use of dynamic and quantitative MRI to investigate the proposed link between knee motion, cartilage contact, and early biomarkers of cartilage degeneration.
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Affiliation(s)
- Jarred M. Kaiser
- Address correspondence to Jarred M. Kaiser, PhD, Department of Mechanical Engineering, University of Wisconsin–Madison, 1513 University Ave, Madison, WI 53706, USA ()
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Evaluation of pivot shift phenomenon while awake and under anaesthesia by different manoeuvres using triaxial accelerometer. Knee Surg Sports Traumatol Arthrosc 2017; 25:2377-2383. [PMID: 26233597 DOI: 10.1007/s00167-015-3740-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 07/24/2015] [Indexed: 01/13/2023]
Abstract
PURPOSE Evaluating pivot shift phenomenon is difficult due to its subjectivity, wide variation of testing manoeuvres, and difficulty in evaluating patients while awake. The purpose of this study was to evaluate the pivot shift phenomenon using a triaxial accelerometer by two different manoeuvres, the pivot shift test as representative of flexion manoeuvre and N test as a representative of extension manoeuvre, and in two different conditions, awake and under anaesthesia. METHODS Twenty-nine patients with unilateral anterior cruciate ligament (ACL)-injured knee were included. Pivot shift test and N test were performed for both injured and uninjured legs while awake and under anaesthesia, with the acceleration measurements using a triaxial accelerometer (KiRA). The tests were also subjectively graded on a scale of 0-6 based on the modification of IKDC criteria. RESULTS Under anaesthesia, acceleration of ACL-injured knees was greater than that of uninjured knees in both pivot shift test (P < 0.001) and N test (P < 0.001) , whereas the acceleration value was greater in the N test. Furthermore, there were significant positive correlations between the acceleration and subjective grading in both tests, whereas the N test was more significant than the pivot shift test. On the other hand, there was no statistical significance in acceleration between ACL-injured and uninjured knees in either test while the patient was awake. CONCLUSION The triaxial accelerometer was useful to objectively detect and quantitatively evaluate the pivot shift phenomenon by both the pivot shift test and N test under anaesthesia. The acceleration of ACL-injured knees was greater than that of uninjured knees, and the acceleration was correlated with the subjective manual grading, especially in the N test. On the other hand, its use while the patient was awake was likely limited. LEVELS OF EVIDENCE Diagnostic study of non-consecutive patients without a universally applied gold standard, Level III.
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Combined reconstruction of the anterior cruciate ligament associated with anterolateral tenodesis effectively controls the acceleration of the tibia during the pivot shift. Knee Surg Sports Traumatol Arthrosc 2017; 25:1117-1124. [PMID: 28349161 DOI: 10.1007/s00167-017-4515-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 03/06/2017] [Indexed: 01/01/2023]
Abstract
PURPOSE The pivot shift test is quantified subjectively during assessment of patients presenting with suspected Anterior Cruciate Ligament (ACL) tears and has a low interobserver reproducibility. The Kinematic Rapid Assessment (KiRA) is a triaxial accelerometer that makes it possible to non-invasively quantify tibial acceleration during the pivot shift test. Abolishing pivot shift is considered to be a key element in surgical reconstruction but is incomplete in 25-38% of patients. METHODS Patients were included prospectively. Inclusion criteria were patients requiring ACL reconstruction associated with at least one of the following factors corresponding to the patient who have a high risk of rupture either by their sports activity, a failure case, or the notion of important rotational laxity: the patient practiced a competitive pivot-contact sport, revision ACL reconstruction (besides STG (semitendinosus-gracilis graft) repair), subjective explosive rotational laxity, Segond fracture, and TELOS value of >10 mm. Standardized pre- and postoperative pivot shift tests were immediately performed under anesthesia in both knees. RESULTS Forty-three patients were included. Mean preoperative variations in tibial acceleration in the healthy and injured knees were 1.2 ± 0.1 and 2.7 ± 0.3 m/s2, respectively, p < 0.01. A statistically significant decrease in immediate postoperative mean variations in acceleration in the injured knee occurred: 1.5 ± 0.3 m/s2, p < 0.01. There was no longer any statistical difference between postoperative contralateral healthy knees and operated knees (n.s). CONCLUSIONS Combined ACL reconstruction associated with anterolateral tenodesis suppress acute pathologic tibial acceleration in the pivot shift. LEVEL OF EVIDENCE III.
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Correlation between a 2D simple image analysis method and 3D bony motion during the pivot shift test. Knee 2016; 23:1059-1063. [PMID: 27810428 DOI: 10.1016/j.knee.2016.06.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 04/16/2016] [Accepted: 06/12/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND The pivot shift test is the most specific clinical test to detect anterior cruciate ligament injury. The purpose of this study was to determine the correlation between the 2D simple image analysis method and the 3D bony motion of the knee during the pivot shift test and assess the intra- and inter-examiner agreements. METHODS Three orthopedic surgeons performed three trials of the standardized pivot shift test in seven knees. Two devices were used to measure motion of the lateral knee compartment simultaneously: 1) 2D simple image analysis method: translation was determined using a tablet computer with custom motion tracking software that quantified movement of three markers attached to skin over bony landmarks; 2) 3D bony motion: electromagnetic tracking system was used to measure movement of the same bony landmarks. RESULTS The 2D simple image analysis method demonstrated a good correlation with the 3D bony motion (Pearson correlation: 0.75, 0.76 and 0.79). The 3D bony translation increased by 2.7 to 3.5 times for every unit increase measured by the 2D simple image analysis method. The mean intra-class correlation coefficients for the three examiners were 0.6 and 0.75, respectively for 3D bony motion and 2D image analyses, while the inter-examiner agreement was 0.65 and 0.73, respectively. CONCLUSIONS The 2D simple image analysis method results are related to 3D bony motion of the lateral knee compartment, even with skin artifact present. This technique is a non-invasive and repeatable tool to quantify the motion of the lateral knee compartment during the pivot shift test.
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Current use of navigation system in ACL surgery: a historical review. Knee Surg Sports Traumatol Arthrosc 2016; 24:3396-3409. [PMID: 27744575 DOI: 10.1007/s00167-016-4356-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 10/07/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE The present review aims to analyse the available literature regarding the use of navigation systems in ACL reconstructive surgery underling the evolution during the years. METHODS A research of indexed scientific papers was performed on PubMed and Cochrane Library database. The research was performed in December 2015 with no publication year restriction. Only English-written papers and related to the terms ACL, NAVIGATION, CAOS and CAS were considered. Two reviewers independently selected only those manuscripts that presented at least the application of navigation system for ACL reconstructive surgery. RESULTS One hundred and forty-six of 394 articles were finally selected. In this analysis, it was possible to review the main uses of navigation system in ACL surgery including tunnel positioning for primary and revision surgery and kinematic assessment of knee laxity before and after different surgical procedures. In the early years, until 2006, navigation system was mainly used to improve tunnel positioning, but since the last decade, this tool has been principally used for kinematics evaluation. Increased accuracy of tunnel placement was observed using navigation surgery, especially, regarding femoral, 42 of 146 articles used navigation to guide tunnel positioning. During the following years, 82 of 146 articles have used navigation system to evaluate intraoperative knee kinematic. In particular, the importance of controlling rotatory laxity to achieve better surgical outcomes has been underlined. CONLUSIONS Several applications have been described and despite the contribution of navigation systems, its potential uses and theoretical advantages, there are still controversies about its clinical benefit. The present papers summarize the most relevant studies that have used navigation system in ACL reconstruction. In particular, the analysis identified four main applications of the navigation systems during ACL reconstructive surgery have been identified: (1) technical assistance for tunnel placement; (2) improvement in knowledge of the kinematic behaviour of ACL and other structures; (3) comparison of effectiveness of different surgical techniques in controlling laxities; (4) navigation system performance to improve the outcomes of ACL reconstruction and cost-effectiveness. LEVEL OF EVIDENCE IV.
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Musahl V, Griffith C, Irrgang JJ, Hoshino Y, Kuroda R, Lopomo N, Zaffagnini S, Samuelsson K, Karlsson J. Validation of Quantitative Measures of Rotatory Knee Laxity. Am J Sports Med 2016; 44:2393-8. [PMID: 27371547 DOI: 10.1177/0363546516650667] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Prior attempts to quantify the pivot-shift examination have been too invasive or impractical for clinical use. A noninvasive method for quantifying rotatory knee laxity is needed. HYPOTHESIS Greater quantitative measurements of rotatory knee laxity (both of the involved knee as well as compared with the contralateral healthy knee) are associated with an increasing clinical pivot-shift grade. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A total of 103 patients undergoing anatomic single-bundle anterior cruciate ligament (ACL) reconstruction at 4 international centers underwent a standardized pivot-shift test preoperatively on both knees while anesthetized. Clinical grading of the pivot shift was performed according to the International Knee Documentation Committee (IKDC) knee ligament rating system. Two different quantitative technologies were used to measure rotatory knee laxity: an inertial sensor and an image analysis were independently used to measure tibial acceleration and lateral compartment translation, respectively, during the pivot-shift test. Patients were dichotomized to "high-grade" (abnormal and severely abnormal) or "low-grade" (normal and nearly normal) rotatory knee laxity groups based on the clinical pivot-shift test result of the involved side. Tibial acceleration and lateral compartment translation of the involved knee and the side-to-side difference between the involved and contralateral knees were separately compared between the high- and low-grade rotatory knee laxity groups utilizing t tests; significance was set at P < .05. RESULTS Forty-three patients were in the low-grade rotatory knee laxity group, and 60 patients were in the high-grade rotatory knee laxity group. Patients in the high-grade knee laxity group had significantly higher lateral compartment translation as measured with the image analysis (involved knee: 3.8 ± 2.3 mm; side-to-side difference: 2.5 ± 2.4 mm) compared with patients in the low-grade group (involved knee: 2.0 ± 1.4 mm; side-to-side difference: 1.4 ± 1.5 mm) (both P < .01). As measured with the inertial sensor, tibial acceleration for patients in the high-grade group was significantly higher (involved knee: 7.2 ± 5.3 m/s(2); side-to-side difference: 4.2 ± 5.4 m/s(2)) compared with patients in the low-grade group (involved knee: 4.2 ± 1.6 m/s(2); side-to-side difference: 1.2 ± 1.2 m/s(2)) (both P < .01). CONCLUSION The inertial sensor and image analysis techniques were able to detect differences between low- and high-grade pivot-shift test results. A quantitative assessment of the pivot-shift test could augment the diagnosis of an ACL injury and improve the ability to detect changes in rotatory knee laxity over time.
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Affiliation(s)
| | - Chad Griffith
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - James J Irrgang
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | | | - Jon Karlsson
- Sahlgrenska University Hospital, Göteborg, Sweden
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Sundemo D, Alentorn-Geli E, Hoshino Y, Musahl V, Karlsson J, Samuelsson K. Objective measures on knee instability: dynamic tests: a review of devices for assessment of dynamic knee laxity through utilization of the pivot shift test. Curr Rev Musculoskelet Med 2016; 9:148-59. [PMID: 26984465 DOI: 10.1007/s12178-016-9338-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Current reconstructive methods used after anterior cruciate ligament (ACL) injury do not entirely restore native knee kinematics. Evaluation of dynamic knee laxity is important to accurately diagnose ACL deficiency, to evaluate reconstructive techniques, and to construct treatment algorithms for patients with ACL injury. The purpose of this study is to present recent progress in evaluation of dynamic knee laxity through utilization of the pivot shift test. A thorough electronic search was performed and relevant studies were assessed. Certain dynamic knee laxity measurement methods have been present for over 10 years (Navigation system, Electromagnetic sensor system) while other methods (Inertial sensor, Image analysis system) have been introduced recently. Methods to evaluate dynamic knee laxity through the pivot shift test are already potent. However, further refinement is warranted. In addition, to correctly quantify the pivot shift test, the involved forces need to be controlled through either standardization or mechanization of the pivot shift test.
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Affiliation(s)
- David Sundemo
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.
| | | | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe Kaisei Hospital, Kobe, Japan
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jón Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
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Quantitative comparison of the pivot shift test results before and after anterior cruciate ligament reconstruction by using the three-dimensional electromagnetic measurement system. Knee Surg Sports Traumatol Arthrosc 2015; 23:2876-81. [PMID: 26342695 DOI: 10.1007/s00167-015-3776-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 08/28/2015] [Indexed: 01/30/2023]
Abstract
PURPOSE Tibial acceleration during the pivot shift test is a potential quantitative parameter to evaluate rotational laxity of anterior cruciate ligament (ACL) insufficiency. However, clinical application of this measurement has not been fully examined. This study aimed to measure and compare tibial acceleration before and after ACL reconstruction (ACLR) in ACL-injured patients. We hypothesized tibial acceleration would be reduced by ACLR and tibial acceleration would be consistent in the same knee at different time points. METHODS Seventy ACL-injured patients who underwent ACLR were enrolled. Tibial acceleration during the pivot shift test was measured using an electromagnetic measurement system before ALCR and at the second-look arthroscopy 1 year post-operatively. Tibial acceleration was compared to clinical grading and between ACL-injured/ACL-reconstructed and contralateral knees. RESULTS Pre-operative tibial acceleration was increased stepwise with the increase in clinical grading (P < 0.01). Tibial acceleration in ACL-injured knee (1.9 ± 1.2 m/s(2)) was larger than that in the contralateral knee (0.8 ± 0.3 m/s(2), P < 0.01), and reduced to 0.9 ± 0.3 m/s(2) post-operatively (P < 0.01). There was no difference between ACL-reconstructed and contralateral knee (n.s.). Tibial acceleration in contralateral knees was consistent pre- and post-operatively (n.s.). CONCLUSION Tibial acceleration measurement demonstrated increased rotational laxity in ACL-injured knees and its reduction by ALCR. Additionally, consistent measurements were obtained in ACL-intact knees at different time points. Therefore, tibial acceleration during the pivot shift test could provide quantitative evaluation of rotational stability before and after ACL reconstruction. LEVEL OF EVIDENCE III.
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Borgstrom PH, Markolf KL, Wang Y, Xu X, Yang PR, Joshi NB, Yeranosian MG, Petrigliano FA, Hame SL, Kaiser WJ, McAllister DR. Use of inertial sensors to predict pivot-shift grade and diagnose an ACL injury during preoperative testing. Am J Sports Med 2015; 43:857-64. [PMID: 25612764 DOI: 10.1177/0363546514565090] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The pivot-shift (PS) examination is used to demonstrate knee instability and detect anterior cruciate ligament (ACL) injury. Prior studies using inertial sensors identified the ACL-deficient knee with reasonable accuracy, but none addressed the more difficult problem of using these sensors to determine whether a subject has an ACL deficiency and to correctly assign a PS grade to a patient's knee. HYPOTHESIS Inertial sensor data recorded during a PS examination can accurately predict ACL deficiency and the PS score assigned by the examining physician. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 2. METHODS A total of 32 patients with unilateral ACL deficiency and 29 with intact ACLs in both knees had inertial sensor modules strapped to the tibia and femur of each limb for preoperative PS testing under anesthesia. Support vector machine (SVM) methods assessed PS grades on the basis of these data, with the examiner's clinical grading shift used as ground truth. A fusion of regression and SVM classification techniques diagnosed ACL deficiency. RESULTS The clinically determined PS grades of all 122 knees were as follows: 0 (n = 69), +1 (n = 23), +2 (n = 27), and +3 (n = 3). The SVM classification analysis was 77% accurate in correctly classifying these grades, with 98% of computed PS grades falling within ±1 grade of the clinically determined value. The system fusion algorithm diagnosed ACL deficiency in an individual with an overall accuracy of 97%. This method yielded 6% false negatives and 0% false positives. CONCLUSION This study used inertial sensor technology with SVM algorithms to accurately determine clinically assigned PS grades in ACL-intact and ACL-deficient knees. By extending the assessment to a separate group of patients without ACL injury, the inertial sensor data demonstrated highly accurate diagnosis of ACL deficiency.
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Affiliation(s)
- Per Henrik Borgstrom
- Wireless Health Initiative, Department of Electrical Engineering, University of California at Los Angeles, Los Angeles, California, USA
| | - Keith L Markolf
- Biomechanics Research Section, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Yan Wang
- Wireless Health Initiative, Department of Electrical Engineering, University of California at Los Angeles, Los Angeles, California, USA
| | - Xiaoyu Xu
- Wireless Health Initiative, Department of Electrical Engineering, University of California at Los Angeles, Los Angeles, California, USA
| | - Paul R Yang
- Biomechanics Research Section, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Nirav B Joshi
- Biomechanics Research Section, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Michael G Yeranosian
- Biomechanics Research Section, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Frank A Petrigliano
- Biomechanics Research Section, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Sharon L Hame
- Biomechanics Research Section, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - William J Kaiser
- Wireless Health Initiative, Department of Electrical Engineering, University of California at Los Angeles, Los Angeles, California, USA
| | - David R McAllister
- Biomechanics Research Section, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
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Muller B, Hofbauer M, Rahnemai-Azar AA, Wolf M, Araki D, Hoshino Y, Araujo P, Debski RE, Irrgang JJ, Fu FH, Musahl V. Development of computer tablet software for clinical quantification of lateral knee compartment translation during the pivot shift test. Comput Methods Biomech Biomed Engin 2015; 19:217-28. [DOI: 10.1080/10255842.2015.1006210] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Kopf S, Musahl V, Bignozzi S, Irrgang JJ, Zaffagnini S, Fu FH. In vivo kinematic evaluation of anatomic double-bundle anterior cruciate ligament reconstruction. Am J Sports Med 2014; 42:2172-7. [PMID: 24961443 DOI: 10.1177/0363546514538958] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is controversy regarding the functional role of the posterolateral (PL) bundle of the anterior cruciate ligament (ACL). PURPOSE To evaluate the in vivo function of the PL and anteromedial (AM) bundles of the ACL during anatomic double-bundle (DB) ACL reconstruction for acute, isolated ACL tears utilizing a computer navigation system to track intraoperative knee kinematics. STUDY DESIGN Controlled laboratory study. METHODS Fifteen patients with acute, isolated ACL tears who underwent anatomic DB ACL reconstruction formed the sample for this study. During surgery, knees were examined by a clinician preoperatively, after fixation of the PL bundle, and after fixation of both the PL and AM bundles. An image-free computer navigation system with custom-made software recorded the data during kinematic tests. The examination consisted of the Lachman and anterior drawer tests, internal-external rotation at 30° of knee flexion, and varus-valgus rotation at 30° of knee flexion. Paired Wilcoxon tests were performed to evaluate the effects of each bundle. The comparisons included ACL-deficient to PL bundle-reconstructed knees, ACL-deficient to DB ACL-reconstructed knees, and PL bundle-reconstructed to DB ACL-reconstructed knees. Significance was set at P < .017 to account for the multiple comparisons. RESULTS Fixation of the PL bundle significantly improved knee laxity during the Lachman and anterior drawer tests as well as internal-external rotation at 30° of knee flexion (P < .017 for all tests). The addition of the AM bundle further improved knee laxity during the Lachman and anterior drawer tests compared with PL bundle fixation as well as during varus-valgus rotation at 30° of knee flexion compared with ACL-deficient knees (P < .017 for all tests). CONCLUSION This in vivo study demonstrates that isolated PL bundle reconstruction improves laxity in an ACL-deficient knee and that the addition of the AM bundle improves laxity parameters further. CLINICAL RELEVANCE Abnormal knee kinematics is known to be linked to the earlier onset of osteoarthritis and lower rates of return to sport. This study suggests that both the AM and PL bundles are important to stabilize ACL-deficient knees.
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Affiliation(s)
- Sebastian Kopf
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Berlin, Germany
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Simone Bignozzi
- Biomechanics Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - James J Irrgang
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Araujo PH, Kfuri Junior M, Ohashi B, Hoshino Y, Zaffagnini S, Samuelsson K, Karlsson J, Fu F, Musahl V. Individualized ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2014; 22:1966-75. [PMID: 24623186 DOI: 10.1007/s00167-014-2928-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 02/25/2014] [Indexed: 01/13/2023]
Abstract
UNLABELLED The pivot shift test is the only physical examination test capable of predicting knee function and osteoarthritis development after an ACL injury. However, because interpretation and performance of the pivot shift are subjective in nature, the validity of the pivot shift is criticized for not providing objective information for a complete surgical planning for the treatment of rotatory knee laxity. The aim of ACL reconstruction was eliminating the pivot shift sign. Many structures and anatomical characteristics can influence the grading of the pivot shift test and are involved in the genesis and magnitude of rotatory instability after an ACL injury. The objective quantification of the pivot shift may be able to categorize knee laxity and provide adequate information on which structures are affected besides the ACL. A new algorithm for rotational instability treatment is presented, accounting for patients' unique anatomical characteristics and objective measurement of the pivot shift sign allowing for an individualized surgical treatment. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Paulo H Araujo
- Department of Biomechanics, Medicine and Rehabilitation of Locomotor System - Ribeirao Preto Medical School, São Paulo University, Av. Bandeirantes, 3900 - Monte Alegre, Ribeirão Prêto, CEP 14049-900, SP, Brazil,
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Musahl V, Zaffagnini S, Becker R, Karlsson J. Should peripheral structures be addressed in ACL reconstruction? Knee Surg Sports Traumatol Arthrosc 2014; 22:1964-5. [PMID: 25056739 DOI: 10.1007/s00167-014-3166-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Volker Musahl
- Department of Orthopaedic Surgery, UPMC Center for Sports Medicine, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA, 15203, USA,
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Use of a gyroscope sensor to quantify tibial motions during a pivot shift test. Knee Surg Sports Traumatol Arthrosc 2014; 22:2064-9. [PMID: 23884298 DOI: 10.1007/s00167-013-2610-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 07/08/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this preliminary study was to evaluate the use of a gyroscope sensor to record rotations of the tibia about its long axis during a clinical pivot shift examination. METHODS Ten patients with a unilateral ACL injury were tested under anaesthesia prior to surgery. Each ankle was placed in neutral position, wrapped and stabilized with athletic tape, and a small aluminium plate was taped to the bottom of the foot. A data recovery module was attached to the bottom of each plate using a swivel bracket that allowed alignment of the gyro axis with the long axis of the tibia. The module contained a triaxial gyroscope, battery and circuitry for wireless data broadcast to a laptop computer. Ten pivot shift tests were performed on both knees, and the surgeon's clinical grading of the pivot shift was noted for each limb. Mean values (10 trials) of peak tibial rotational velocity and integrated tibial rotation were compared between knees for each patient during the pivot shift reduction event (external tibial rotation during knee flexion). RESULTS Five patients (50%) had significantly greater tibial rotation in their injured knee, four showed no difference between knees, and one had significantly greater rotation in the normal knee (p < 0.05). Seven patients (70%) showed greater peak rotational velocity in their injured knee, and three had no difference between the knees (p < 0.05). Correlations of rotation and rotational velocity with clinical pivot shift grade were weak (r2 = 0.09 and 0.19, respectively). CONCLUSIONS Foot gyroscope measurements did not correctly identify the injured limb in all patients. Peak rotational velocity during the reduction event was a better indicator of ACL deficiency than the integrated rotation. If this technology is to be more useful clinically, gyroscope data may have to be combined with accelerometer data, perhaps with sensors mounted on both the tibia and femur. LEVEL OF EVIDENCE Diagnostic case-control study, Level III.
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Asai S, Maeyama A, Hoshino Y, Goto B, Celentano U, Moriyama S, Smolinski P, Fu FH. A comparison of dynamic rotational knee instability between anatomic single-bundle and over-the-top anterior cruciate ligament reconstruction using triaxial accelerometry. Knee Surg Sports Traumatol Arthrosc 2014; 22:972-8. [PMID: 23568389 DOI: 10.1007/s00167-013-2499-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 04/02/2013] [Indexed: 12/18/2022]
Abstract
PURPOSE Recently, single-bundle (SB) anterior cruciate ligament (ACL) reconstruction has been advanced by the anatomic concept, but the biomechanical outcome of the anatomic method has not been fully investigated, especially for rotational instability. Anatomic SB and the single over-the-top procedures are the treatment of choice for primary cases and revision or skeletally immature cases, respectively. The purpose of this study was to investigate the dynamic rotational instability of anatomic SB and over-the-top reconstruction during a pivot shift test using triaxial accelerometry. METHODS Eight fresh frozen human cadaveric knees were used in this study. Rotational instability measurement was conducted during a pivot shift test by the use of a triaxial accelerometer attached to the tibia. The tests were performed in the ACL-intact, ACL-deficient and ACL-reconstructed knees with two different procedures (anatomic SB and over-the-top). The acceleration in three directions and the magnitude of acceleration were measured to evaluate rotational instability and compare between four different knee states. RESULTS The overall magnitude of acceleration was significantly different (P < 0.01) between the ACL-intact knees and the ACL-deficient knees. Both anatomic SB and over-the-top ACL reconstruction significantly reduced the overall magnitude of acceleration compared to the ACL-deficient knees, but still had larger accelerations compared to the ACL-intact knees. There was no significant difference for the overall magnitude of acceleration between anatomic SB and over-the-top reconstruction procedure. CONCLUSION Over-the-top reconstruction provides comparable result to anatomic SB reconstruction in terms of controlling the dynamic rotational stability. Over-the-top reconstruction might be one of the options for revision cases and in skeletally immature patients.
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Affiliation(s)
- Shigehiro Asai
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Russell DF, Deakin AH, Fogg QA, Picard F. Non-invasive, non-radiological quantificationof anteroposterior knee joint ligamentous laxity: A study in cadavers. Bone Joint Res 2013; 2:233-7. [PMID: 24184443 PMCID: PMC3819608 DOI: 10.1302/2046-3758.211.2000199] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES We performed in vitro validation of a non-invasive skin-mounted system that could allow quantification of anteroposterior (AP) laxity in the outpatient setting. METHODS A total of 12 cadaveric lower limbs were tested with a commercial image-free navigation system using trackers secured by bone screws. We then tested a non-invasive fabric-strap system. The lower limb was secured at 10° intervals from 0° to 60° of knee flexion and 100 N of force was applied perpendicular to the tibia. Acceptable coefficient of repeatability (CR) and limits of agreement (LOA) of 3 mm were set based on diagnostic criteria for anterior cruciate ligament (ACL) insufficiency. RESULTS Reliability and precision within the individual invasive and non-invasive systems was acceptable throughout the range of flexion tested (intra-class correlation coefficient 0.88, CR 1.6 mm). Agreement between the two systems was acceptable measuring AP laxity between full extension and 40° knee flexion (LOA 2.9 mm). Beyond 40° of flexion, agreement between the systems was unacceptable (LOA > 3 mm). CONCLUSIONS These results indicate that from full knee extension to 40° flexion, non-invasive navigation-based quantification of AP tibial translation is as accurate as the standard validated commercial system, particularly in the clinically and functionally important range of 20° to 30° knee flexion. This could be useful in diagnosis and post-operative evaluation of ACL pathology. Cite this article: Bone Joint Res 2013;2:233-7.
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Affiliation(s)
- D F Russell
- Golden Jubilee National Hospital, OrthopaedicDepartment, Agamemnon Street, Clydebank, WestDunbartonshire G81 4DY, and Faculty of Biomedicaland Life Sciences, Thomson Building, University Avenue, GlasgowG12 8QQ, UK
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Quantitative evaluation of the pivot shift by image analysis using the iPad. Knee Surg Sports Traumatol Arthrosc 2013; 21:975-80. [PMID: 23340837 DOI: 10.1007/s00167-013-2396-0] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 01/11/2013] [Indexed: 01/15/2023]
Abstract
PURPOSE To enable comparison of test results, a widely available measurement system for the pivot shift test is needed. Simple image analysis of lateral knee joint translation is one such system that can be installed on a prevalent computer tablet (e.g. iPad). The purpose of this study was to test a novel iPad application to detect the pivot shift. It was hypothesized that the abnormal lateral translation in ACL deficient knees would be detected by the iPad application. METHODS Thirty-four consecutive ACL deficient patients were tested. Three skin markers were attached on the following bony landmarks: (1) Gerdy's tubercle, (2) fibular head and (3) lateral epicondyle. A standardized pivot shift test was performed under anaesthesia, while the lateral side of the knee joint was monitored. The recorded movie was processed by the iPad application to measure the lateral translation of the knee joint. Lateral translation was compared between knees with different pivot shift grades. RESULTS Valid data sets were obtained in 20 (59 %) ACL deficient knees. The remaining 14 data sets were invalid because of failure to detect translation or detection of excessive translation. ACL deficient knees had larger lateral translation than the contra-lateral knees (p < 0.01). In the 20 valid data sets, which were graded as either grade 1 (n = 10) or grade 2 (n = 10), lateral translation was significantly larger in the grade 2 pivot shift (3.6 ± 1.2 mm) than the grade 1 pivot shift (2.7 ± 0.6 mm, p < 0.05). CONCLUSION Although some technical corrections, such as testing manoeuvre and recording procedure, are needed to improve the image data sampling using the iPad application, the potential of the iPad application to classify the pivot shift was demonstrated.
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Lopomo N, Zaffagnini S, Amis AA. Quantifying the pivot shift test: a systematic review. Knee Surg Sports Traumatol Arthrosc 2013; 21:767-83. [PMID: 23455384 DOI: 10.1007/s00167-013-2435-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 01/23/2013] [Indexed: 01/13/2023]
Abstract
PURPOSE This study aims to identify and summarize the evidence on the biomechanical parameters and the corresponding technologies which have been used to quantify the pivot shift test during the clinical and functional assessment of anterior cruciate ligament (ACL) injury and surgical reconstruction. METHODS Search strategy Internet search of indexed scientific articles on the PubMed database, Web of Science and references on published manuscripts. No year restriction was used. Selection criteria Articles included were written only in English and related to search terms: "pivot shift" AND (OR "ACL"). The reviewers independently selected only those studies that included at least one quantitative parameter for the analysis of the pivot shift test, including both in vitro and in vivo analyses performed on human joint. Those studies that analysed only clinical grading were excluded from the analysis. Analysis After evaluating the methodological quality of the articles, the parameters found were summarized. RESULTS Six hundred and eight studies met the inclusion criteria, and finally, 68 unique studies were available for the systematic review. Quantitative results were heterogeneous. The pivot shift test has been quantified by means of 25 parameters, but most of the studies focused on anterior-posterior translations, internal-external rotation and acceleration in anterior-posterior direction. CONCLUSION Several methodologies have been identified and developed to quantify pivot shift test. However, clinical professionals are still lacking a 'gold standard' method for the quantification of knee joint dynamic laxity. A widespread adoption of a standardized pivot shift manoeuvre and measurement method to allow objective comparison of the results of ACL reconstructions is therefore desirable. Further development of measurement methods is indeed required to achieve this goal in a routine clinical scenario.
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Affiliation(s)
- Nicola Lopomo
- Laboratorio di Biomeccanica e Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136, Bologna, Italy.
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Abstract
Evaluation of injured-knee laxity is essential for treatment selection, clinical follow-up, and research. Interest in rotatory knee laxity increased with implementation of anatomic anterior cruciate ligament reconstruction. The pivot shift test represents a link between static testing with 1° of freedom and dynamic testing during functional activity. Difficulties lie in standardizing the performance of the pivot shift test and extracting measurable and relevant kinematic data. Noninvasive methodologies based on electromagnetic or acceleration sensors can evaluate the pivot shift in a quantitative and reliable manner. Further validation and reliability testing of devices for examination of rotatory laxity is warranted.
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Affiliation(s)
- Mattias Ahldén
- Department of Orthopaedics, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital/Mölndal, Sweden.
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Colombet P, Jenny JY, Menetrey J, Plaweski S, Zaffagnini S. Current concept in rotational laxity control and evaluation in ACL reconstruction. Orthop Traumatol Surg Res 2012; 98:S201-10. [PMID: 23153665 DOI: 10.1016/j.otsr.2012.10.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Accepted: 09/25/2012] [Indexed: 02/02/2023]
Abstract
Rotation combined with translation; compose the three-dimensional motion of the knee subluxation in anterior cruciate ligament deficient knee. The worldwide scientists were focused initially on the translation part of this complex 3D motion, but since the beginning of the century there was a large interest on knee rotational laxity study. Lot of paper reported new devices and results with an explosion since the beginning of the decade. The purpose of this review is to provide an extensive critical analysis of the literature and clarify the knowledge on this topic. We will start with a dismemberment of different rotational laxities reported: the rotation coupled with translation in 2D tests such as Lachman test and anterior drawer test; the rotational envelope considering the maximum internal external rotation; and the "active rotation" occurring in 3D Pivot-shift (PS) test. Then we will analyze the knee kinematics and the role of different anterior cruciate ligament (ACL) bundle on rotation. A review of different mechanical and radiological devices used to assess the different rotations on ACL deficient knees will be presented. Two groups will be analyzed, dynamic and static conditions of tests. Navigation will be described precisely; it was the starter of this recent interest in rotation studies. Opto electronic and electromagnetic navigation systems will be presented and analyzed. We will conclude with the last generation of rotational laxity assessment devices, using accelerometers, which are very promising.
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Affiliation(s)
- P Colombet
- Clinique du sport, 9, rue Jean-Moulin, 33700 Mérignac, France.
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WANG LIZHEN, ZHAO FENG, HAN JINGYUN, WANG CHAO, FAN YUBO. BIOMECHANICAL STUDY ON PROXIMAL FEMORAL NAIL ANTIROTATION (PFNA) FOR INTERTROCHANTERIC FRACTURE. J MECH MED BIOL 2012. [DOI: 10.1142/s0219519412005125] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The proximal femoral nail antirotation device (PFNA) is a typical implant to the treatment of intertrochanteric fractures. However, re-fracture of the femur shaft after nailing are usually been reported. The purpose of this study was to investigate the biomechanical features in the healed proximal femur at different stages in the healing process. Stress and strain distributions, total strain energy density (SED) along the femur and PFNA were analyzed in walking and stair climbing. Results showed remarkable stress concentration occurred near the locking bolt hole with retained PFNA, decreased after PFNA removal. Stair climbing resulted in higher strain at the locking bolt hole than normal walking. The conclusion can be drawn that non-removal of PFNA after healing may result in high fractural risk near locking bolt on femoral shaft. Meanwhile, stair climbing should be avoided during healing.
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Affiliation(s)
- LIZHEN WANG
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, 100191 Beijing, China
| | - FENG ZHAO
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, 100191 Beijing, China
| | - JINGYUN HAN
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, 100191 Beijing, China
| | - CHAO WANG
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, 100191 Beijing, China
| | - YUBO FAN
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, 100191 Beijing, China
- National Key Lab of Virtual Reality Technology, Beihang University, 100191 Beijing, China
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Innovative technology for knee laxity evaluation: clinical applicability and reliability of inertial sensors for quantitative analysis of the pivot-shift test. Clin Sports Med 2012. [PMID: 23177462 DOI: 10.1016/j.csm.2012.08.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
There has been an increased interest in the quantification of the knee laxity secondary to anterior cruciate ligament (ACL) injury. In clinical practice, the diagnosis is performed by clinical examination and magnetic resonance imaging analysis and confirmed arthroscopically. The pivot shift phenomenon has been identified as one of the essential signs of functional ACL insufficiency. A reliable system to adequately assess patients with ACL injury, quantifying the pivot shift test outcome, is needed. Several studies have been conducted in this regard but the proposed methods remain confined to a research area. The goal of this article is to summarize the actual knowledge and current concepts.
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Optimal measurement of clinical rotational test for evaluating anterior cruciate ligament insufficiency. Knee Surg Sports Traumatol Arthrosc 2012; 20:1323-30. [PMID: 21850429 DOI: 10.1007/s00167-011-1643-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 07/29/2011] [Indexed: 01/24/2023]
Abstract
PURPOSE Rotational instability in ACL insufficient knee addresses the symptom or the abnormal motion which can be reproduced and subjectively evaluated in the clinical exam. Clinically available quantitative measurement for this instability has not been established due to mixed testing maneuvers and complex kinematics. The purpose was to measure knee kinematics during three manually performed rotational tests and to determine the optimal method to detect the abnormality in ACL deficient knees. METHOD Thirteen unilateral ACL deficient patients were tested by internal and external pure rotational stress tests and pivot shift test under anesthesia before scheduled ACL reconstructions. Rotation and coupled motion, i.e., tibial anteroposterior translation, were measured using an electromagnetic measurement system. Additionally, the acceleration of the tibial posterior translation during pivot shift test was calculated. The differences of these parameters between ACL intact and deficient knees were tested. RESULTS Knee rotation is not different between ACL intact and deficient during both pure rotational stress test and pivot shift test. The coupled anterior tibial translation during pivot shift test was significantly different between ACL intact, 13.5 ± 4.1 mm, and deficient knees, 23.1 ± 4.4 mm, (P < 0.01) as well as the acceleration of the tibial posterior translation (1.1 ± 0.4 m/sec(2) in intact knees, 3.2 ± 1.5 m/sec(2) in deficient knees; P < 0.01). The coupled motion during pure rotational stress tests was similar regardless of ACL condition. CONCLUSION The rotational instability of the ACL deficiency was reproduced only by the pivot shift test and detected only by measuring the tibial anteroposterior translation and acceleration of the tibial posterior reduction. Level of evidence Diagnostic study, Level III.
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Lorbach O, Kieb M, Brogard P, Maas S, Pape D, Seil R. Static rotational and sagittal knee laxity measurements after reconstruction of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 2012; 20:844-50. [PMID: 21811853 DOI: 10.1007/s00167-011-1635-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 07/20/2011] [Indexed: 12/25/2022]
Abstract
PURPOSE The goal of the present study was to evaluate static anteroposterior and rotational knee laxity after ACL reconstructions with two noninvasive measurement devices by comparing the measured results of the operated with the contralateral healthy knees of the patients. METHODS Fifty-two consecutive patients were reviewed after isolated single-bundle transtibial ACL reconstruction using a BPTB graft. At a mean follow-up of 27 months, sagittal AP laxity was tested using a noninvasive knee measurement system (Genourob) with an applied pressure of 67 N, 89 N and 134 N. Rotational laxity was measured using a noninvasive rotational knee laxity device (Rotameter) with an applied torque of 5, 8 and 10 Nm. The results were compared with the measurements of the patients' healthy contralateral knees. Tegner, Lysholm and IKDC score were used in order to evaluate the clinical outcome. RESULTS Pivot shift was negative (33) or glide (16) in 49 patients with 12 of 16 (75%) patients having also a pivot glide on the healthy contralateral side; Lachman tests were negative in 50 cases. Subjective assessment of the IKDC score was classified according to category A in 44 patients, B in 5 patients and C in 3 patients. Mean Lysholm score was 94.5 ± 9.5, median Tegner score was 7 (3-9) preoperative and 6 (3-9) at follow-up (n.s.). Anteroposterior knee laxity measurements revealed mean side-to-side differences of 0.6-1.3 mm (P < 0.0001). Rotational laxity measurements revealed no statistical significant differences between the operated and the contralateral knee (n.s.). The measured differences in the entire rotational range varied from 0.2° to 1° depending on the applied torque. In those 3 patients with a positive pivot shift, differences in the entire rotational range of 4.5° at 5 N, 4.6° at 8 N and 4.1° at 10 N were found. CONCLUSION Static knee laxity was quantified after ACL surgery using the introduced noninvasive measurement systems by comparing the measured results of the operated with the contralateral healthy knees. Significant differences were found in AP laxity although they were defined as clinically successful according to the IKDC classification. No significant differences were found in rotational knee laxity measurements. Therefore, the used noninvasive masurement devices might offer a high potential for objective quality control in knee ligament injuries and their treatment. LEVEL OF EVIDENCE Retrospective case series, Level IV.
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Affiliation(s)
- O Lorbach
- Department of Orthopedic Surgery, Saarland University, Kirrberger Street, Homburg, Saarland, Germany.
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Standardized pivot shift test improves measurement accuracy. Knee Surg Sports Traumatol Arthrosc 2012; 20:732-6. [PMID: 22205096 DOI: 10.1007/s00167-011-1850-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 12/16/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE The variability of the pivot shift test techniques greatly interferes with achieving a quantitative and generally comparable measurement. The purpose of this study was to compare the variation of the quantitative pivot shift measurements with different surgeons' preferred techniques to a standardized technique. The hypothesis was that standardizing the pivot shift test would improve consistency in the quantitative evaluation when compared with surgeon-specific techniques. METHODS A whole lower body cadaveric specimen was prepared to have a low-grade pivot shift on one side and high-grade pivot shift on the other side. Twelve expert surgeons performed the pivot shift test using (1) their preferred technique and (2) a standardized technique. Electromagnetic tracking was utilized to measure anterior tibial translation and acceleration of the reduction during the pivot shift test. The variation of the measurement was compared between the surgeons' preferred technique and the standardized technique. RESULTS The anterior tibial translation during pivot shift test was similar between using surgeons' preferred technique (left 24.0 ± 4.3 mm; right 15.5 ± 3.8 mm) and using standardized technique (left 25.1 ± 3.2 mm; right 15.6 ± 4.0 mm; n.s.). However, the variation in acceleration was significantly smaller with the standardized technique (left 3.0 ± 1.3 mm/s(2); right 2.5 ± 0.7 mm/s(2)) compared with the surgeons' preferred technique (left 4.3 ± 3.3 mm/s(2); right 3.4 ± 2.3 mm/s(2); both P < 0.01). CONCLUSION Standardizing the pivot shift test maneuver provides a more consistent quantitative evaluation and may be helpful in designing future multicenter clinical outcome trials. LEVEL OF EVIDENCE Diagnostic study, Level I.
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Comparison of anterior and rotatory laxity using navigation between single- and double-bundle ACL reconstruction: prospective randomized trial. Knee Surg Sports Traumatol Arthrosc 2012; 20:752-61. [PMID: 22273781 DOI: 10.1007/s00167-012-1880-2] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 01/06/2012] [Indexed: 10/14/2022]
Abstract
PURPOSE To prospectively assess the anterior tibial translation and rotational kinematics of the knee joint as well as the clinical outcome after single-bundle (SB) and double-bundle (DB) anterior cruciate ligament (ACL) reconstruction. METHODS Forty-two patients randomly underwent single-bundle (Group SB, n = 21) or double-bundle (Group DB, n = 21) ACL reconstruction using hamstring tendon autografts. Anterior tibial translation and rotatory laxity were measured prior to and after fixation of the graft during reconstruction under the guidance of a navigation system. Clinical outcome measurements included the evaluation of the joint stability and functional status. RESULTS Anterior tibial translation and rotatory laxity were improved significantly at all degrees of knee flexion in both groups. The postoperative total rotation (sum of internal and external rotation) at 30° and 60° (26.6° vs. 24.0°; 28.7° vs. 25.1°) as well as postoperative change in external rotation at 60° (-1.4° vs. -4.6°), and a change in total rotation at 30° and 60° (-7.0° vs. -11.5°; -6.1° vs. -8.9°) differed between the two groups, with better stability in the DB group. At 2 years follow-up, IKDC subjective satisfaction score was significantly different between two groups (70.9 vs. 79.6), while manual and instrumented laxity, pivot shift tests, modified Lysholm score, Tegner activity score, thigh muscle strengths were not different. Correlation analysis showed little correlations between anterior laxity tests at follow-up, and the kinematic variables measured by navigation during surgery while pivot shift test, IKDC subjective satisfaction score, modified Lysholm score, and Tegner activity score were mainly correlated with navigation-measured rotations in both groups. CONCLUSIONS The kinematic tests in this study found evidence suggesting that the DB ACL reconstruction improved rotatory laxity better than the SB ACL reconstruction at 30° and 60° of flexion, but there was no difference in functional outcome at 2 years follow-up between SB and DB groups. LEVEL OF EVIDENCE Prospective comparative study, Level II.
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Lopomo N, Signorelli C, Bonanzinga T, Marcheggiani Muccioli GM, Visani A, Zaffagnini S. Quantitative assessment of pivot-shift using inertial sensors. Knee Surg Sports Traumatol Arthrosc 2012; 20:713-7. [PMID: 22222615 DOI: 10.1007/s00167-011-1865-6] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Accepted: 12/21/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE The pivot-shift phenomenon has been identified to be one of the essential signs of functional anterior cruciate ligament (ACL) insufficiency. However, the pivot-shift test remains a surgeon-subjective examination, lacking a general recognized quantitative measurement. The goal of the present study was to validate the use of an inertial sensor for quantifying the pivot-shift test, using a commercial navigation system. METHODS An expert surgeon intra-operatively performed the pivot-shift test on 15 consecutive patients before ACL reconstruction. A single accelerometer and a commercial navigation system simultaneously acquired limb kinematics. An additional optical tracker mounted on the accelerometer allowed following sensor movements. Anteroposterior (a-p) tibial acceleration obtained with the navigation system was compared with three-dimensional (3D) acceleration acquired by the accelerometer. The effect of skin artifacts and test-retest positioning were estimated. Repeatability of the acceleration parameter and waveform was analyzed. Correlation between the two measurements was also assessed. RESULTS Average root mean square (RMS) error in test-retest positioning reported a good value of 5.5 ± 2.9 mm. Mean RMS displacement due to soft tissue artifacts was 4.9 ± 2.6 mm. The analysis of acceleration range repetitions reported a good intra-tester repeatability (Cronbach's alpha = 0.86). Inter-patients similarity analysis showed a mean acceleration waveform correlation of 0.88 ± 0.14. The acceleration ranges demonstrated a good positive correlation between the two measurements (rs = 0.72, P < 0.05). CONCLUSION This study showed good reliability of the new device and good correlation with the navigation system results. Therefore, the accelerometer is a valid method to assess dynamic joint laxity. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Nicola Lopomo
- Laboratorio di Biomeccanica e Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Via Di Barbiano, 1/10, 40136 Bologna, Italy.
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Lorbach O, Brockmeyer M, Kieb M, Zerbe T, Pape D, Seil R. Objective measurement devices to assess static rotational knee laxity: focus on the Rotameter. Knee Surg Sports Traumatol Arthrosc 2012; 20:639-44. [PMID: 22246547 DOI: 10.1007/s00167-011-1876-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 12/30/2011] [Indexed: 01/15/2023]
Abstract
PURPOSE The present article summarizes the development of a simple, objective, and non-invasive measurement device for tibiofemoral rotation to assess static rotational knee laxity. METHODS AND RESULTS The device is based on the dial test with the patient lying prone and the knee flexed to 30°. From measurements of 30 healthy participants, the device achieved high inter- and intra-observer reliability and showed a high correlation of the measured results with the contralateral knees of the participants. Measurements of the device were also performed in a human cadaver study and revealed highly correlated results when compared to the simultaneous measurements of a knee navigation system, which was used as an invasive standard method to assess tibial rotation. In human cadaver specimens, it was shown that a simulated tear of the posterolateral bundle as well as a complete ACL tear led to a significant increase in isolated tibiofemoral rotation compared to the intact ACL. A retrospective case series investigated the clinical results as well as knee laxity measurements after ACL surgery in vivo. Rotational, as well as anteroposterior (AP), knee laxity was objectively assessed in 52 patients at a mean postoperative follow-up of 27 months by comparing the measured results with the results of the contralateral unaffected knee in each patient. The clinical results were comparable to the results reported in the literature. Moreover, rotational laxity was successfully restored after ACL reconstruction, whereas AP laxity showed significant differences compared to the contralateral knees although they were defined as clinically successful according to the IKDC classification. CONCLUSIONS A non-invasive and objective knee rotational measurement device has been developed, which offers good potential for objective quality control in knee ligament injuries and their treatment. LEVEL OF EVIDENCE Review article, Level IV.
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Affiliation(s)
- Olaf Lorbach
- Department of Orthopedic Surgery, Saarland University, Kirrberger Str., 66421 Homburg (Saar), Germany.
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Musahl V, Kopf S, Rabuck S, Becker R, van der Merwe W, Zaffagnini S, Fu FH, Karlsson J. Rotatory knee laxity tests and the pivot shift as tools for ACL treatment algorithm. Knee Surg Sports Traumatol Arthrosc 2012; 20:793-800. [PMID: 22207028 DOI: 10.1007/s00167-011-1857-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 12/19/2011] [Indexed: 11/30/2022]
Abstract
UNLABELLED The goal of anterior cruciate ligament (ACL) reconstruction surgery is to eliminate the pivot shift phenomenon. Different injury mechanisms and injury patterns may lead to specific knee laxity patterns. Computer navigation is helpful for the surgeon during examination under anesthesia. Surgical treatment may have to be altered if high-grade laxity is detected preoperatively for example by utilizing a computer navigation that is a helpful adjunct for surgeons during examination under anesthesia. A typical case for revision ACL reconstruction is presented. This article describes several techniques of laxity assessments. Based on the type and degree of pathologic laxity, a treatment algorithm has been developed. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Volker Musahl
- Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA 15203, USA.
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Araujo PH, Ahlden M, Hoshino Y, Muller B, Moloney G, Fu FH, Musahl V. Comparison of three non-invasive quantitative measurement systems for the pivot shift test. Knee Surg Sports Traumatol Arthrosc 2012; 20:692-7. [PMID: 22218829 DOI: 10.1007/s00167-011-1862-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 12/22/2011] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to evaluate three different non-invasive measuring devices for the pivot shift phenomenon with reference to direct bony movement measured by an electromagnetic device rigidly attached to the tibia and femur. METHODS A lower body cadaveric specimen was prepared to create a positive pivot shift in both knees. Twelve expert knee surgeons from worldwide performed their preferred pivot shift technique three times in each knee. After watching an instructional video, the examiners used a standardized technique to perform three additional pivot shift maneuvers in each knee. An electromagnetic tracking system, rigidly attached to femur and tibia, was used to provide reference measurements during the pivot shift test. Three different devices were correlated to the reference method and evaluated in this study: (1) Electromagnetic tracking system with skin sensors; (2) Triaxial accelerometer system; (3) Simple image analysis. RESULTS When results from both pivot shift techniques (preferred and standardized) were combined, the electromagnetic tracking system with skin sensors showed positive correlation with the reference measurement for acceleration and translation parameters (r = 0.88 and r = 0.67, respectively; both P < 0.01); The triaxial accelerometer system demonstrated good correlation with the reference measurement for acceleration (r = 0.75; P < 0.001). The image analysis system was poorly correlated to the translation of the reference measurement (r = 0.24; P < 0.01). CONCLUSION The electromagnetic tracking system with skin sensors provided the best correlation with the reference method. The triaxial accelerometer showed also a good correlation and the image analysis system showed a positive, but poor correlation with the reference method. More research is needed in order to validate simple and non-invasive devices for clinical application.
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Affiliation(s)
- Paulo H Araujo
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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Kuroda R, Hoshino Y, Araki D, Nishizawa Y, Nagamune K, Matsumoto T, Kubo S, Matsushita T, Kurosaka M. Quantitative measurement of the pivot shift, reliability, and clinical applications. Knee Surg Sports Traumatol Arthrosc 2012; 20:686-91. [PMID: 22210517 DOI: 10.1007/s00167-011-1849-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 12/16/2011] [Indexed: 02/07/2023]
Abstract
Static load-displacement measurement is unrelated to the dynamic knee function of anterior cruciate ligament (ACL) insufficiency. Performing an accurate, dynamic functional evaluation is necessary not only for the primary ACL injury, but also as an outcome measurement in ACL reconstruction. The pivot shift test is commonly used for assessing dynamic rotatory knee laxity in ACL-insufficient knees and is related to subjective knee function. Residual pivot shift after ACL reconstruction is a crucial factor related to poor clinical outcome. However, the pivot shift test is subjectively determined by the examiners' hands. Not only 3-dimensional (3D) position displacement but also its 3D acceleration should be measured for quantitative evaluation of the pivot shift test and is currently feasible by using recent advanced technology, i.e., electromagnetic devices. We summarize the basic knowledge and current concepts of quantitative exploration of the dynamic knee movement during the pivot shift test.
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Affiliation(s)
- Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650-0017, Japan.
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An image analysis method to quantify the lateral pivot shift test. Knee Surg Sports Traumatol Arthrosc 2012; 20:703-7. [PMID: 22203048 PMCID: PMC3309139 DOI: 10.1007/s00167-011-1845-x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2011] [Accepted: 12/15/2011] [Indexed: 12/20/2022]
Abstract
PURPOSE Although various kinematic measurements with advanced technology have been used for quantitative evaluation of the pivot shift test, there is no clinically available quantification method of the pivot shift test. The purpose was to describe a novel image analysis technique for quantitative assessment of the pivot shift test using universally available and affordable devices. METHODS Five ACL deficient knees were tested during examination under anesthesia. Three skin markers were attached to bony landmarks on the lateral side of the knee joint, (1) Gerdy's tubercle, (2) fibular head, and (3) lateral epicondyle. A standard digital video camera captured motion of the lateral aspect of the knee during the pivot shift test. The image was processed into a 2-dimensional (2-D) coordinate system with Image J software (National Institute of Health, USA) to trace the three landmarks. The anteroposterior (AP) position of the femur was calculated on consecutive still images extracted from the video recording. AP translation over time was reported. RESULTS The reduction phase of the pivot shift could be tracked consistently by a sudden anterior translation of the distal femur. The sudden anterior translation of the lateral epicondyle was on average 3.7 ± 2.1 mm and occurred within 0.2 ± 0.1 s from the start of this anterior translation till the end. CONCLUSION The sudden shift of the lateral compartment of the knee joint was successfully detected by this newly developed image analysis measurement method. This image analysis technique facilitates a simple and affordable method to evaluate the lateral pivot shift test. LEVEL OF EVIDENCE Diagnostic studies, Level IV.
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Anterior cruciate ligament reconstruction using 4-strand hamstring autograft: conventional single-bundle technique versus oval-footprint technique. Arthroscopy 2011; 27:1502-10. [PMID: 21924856 DOI: 10.1016/j.arthro.2011.06.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 06/04/2011] [Accepted: 06/21/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to compare short-term results of conventional anterior cruciate ligament (ACL) reconstruction with oval-footprint (modified) single-tunnel ACL reconstruction with 4-strand hamstring autograft. METHODS A prospective comparative study was performed in 74 consecutive subjects who underwent ACL reconstruction with the conventional technique (group I, 40 cases) or the modified technique (group II, 34 cases), in which the entrances of the femoral and tibial tunnels were more elongated, by use of 4-strand hamstring tendon. The Lachman test, pivot-shift test, range of motion, International Knee Documentation Committee classification, Lysholm score, and side-to-side differences were evaluated preoperatively and at the last follow-up. The Tegner activity scale was evaluated before injury and at the last follow-up. RESULTS There were 38 patients in group I and 32 in group II who were followed up for at least 2 years (mean follow-up, 32.4 months). At the last follow-up, Lachman test results were negative in 34 in group I and 30 in group II (P = .624) and the pivot-shift test was negative in 32 in group I and 30 in group II (P = .397). Mean range of motion of the injured knee was 142.2° in group I and 141.9° in group II (P = .771). The International Knee Documentation Committee classification was A or B in 37 in group I and 31 in group II (P = .872). The median Lysholm score was 94 in group I and 96 in group II (P = .048). The mean side-to-side difference averaged 2.08 mm in group I and 2.07 mm in group II (P = .943). The median score on the Tegner activity scale was 6 in group I and 6 in group II (P = .968). CONCLUSIONS The Lysholm score in the modified-technique group at the last follow-up was better than that in the conventional-technique group in terms of statistical significance, but this may not be clinically significant. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Mayr HO, Hoell A, Bernstein A, Hube R, Zeiler C, Kalteis T, Suedkamp NP, Stoehr A. Validation of a measurement device for instrumented quantification of anterior translation and rotational assessment of the knee. Arthroscopy 2011; 27:1096-104. [PMID: 21641751 DOI: 10.1016/j.arthro.2011.02.034] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2010] [Revised: 02/20/2011] [Accepted: 02/24/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE A test setup for clinical use in the awake and non-anesthetized patient measuring anteroposterior translation and rotation of the knee joint is the subject of validation. METHODS A measuring device featuring fixation of the foot at 30° of knee flexion with varus/valgus stress posts for the knee was developed. Tibial rotation (external/internal) was imposed with a torque of 2 Nm on the footrest with the ankle locked in dorsiflexion. Anterior translation of the tibia in relation to the femur was measured with a commercially available arthrometer. Measurements were performed in a neutral position, internal rotation, and external rotation. Intrarater and inter-rater reliability was validated in 10 healthy volunteers (Cronbach α). We examined 10 patients with isolated anterior cruciate ligament (ACL) rupture, as well as 10 patients with ACL rupture plus medial instability and 10 patients with additional lateral instability. Side-to-side differences were used for calculation. RESULTS Comparison of healthy volunteers and subjects with isolated ACL rupture showed significant differences: internal rotation, 0.79 mm and 2.46 mm, respectively (P = .001); neutral position, 0.4 mm and 3.35 mm, respectively (P < .0001); and external rotation, 0.29 mm and 2.5 mm, respectively (P = .003). Significant differences (P = .008) were found between isolated ACL rupture and ACL rupture plus medial instability by use of the ratio of anterior translation in external rotation versus the neutral position. Inter-rater reliability was 0.948 in 10 healthy volunteers and 0.981 in 10 subjects with unilateral ACL rupture. Intrarater reliability in the volunteers was 0.829. CONCLUSIONS By use of the developed measurement device, the "Laxitester" (ORTEMA Sport Protection, Markgroeningen, Germany), objective differentiation between isolated ACL rupture and ACL rupture plus additional medial instability is possible. Values for anterior translation are reliable and reproducible by different examiners and by the same examiner at different times. CLINICAL RELEVANCE The Laxitester allows objectification of medial instability in combination with ACL injuries and provides a reference regarding the need for additional medial stabilization. Compared with the isolated measurement of anteroposterior translation, knee instability can be assessed in a more differentiated manner.
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Affiliation(s)
- Hermann O Mayr
- Department of Orthopedic and Trauma Surgery, Albert Ludwig University of Freiburg, Freiburg, Germany.
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Plaweski S, Grimaldi M, Courvoisier A, Wimsey S. Intraoperative comparisons of knee kinematics of double-bundle versus single-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2011; 19:1277-86. [PMID: 21311868 DOI: 10.1007/s00167-011-1405-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Accepted: 01/13/2011] [Indexed: 01/30/2023]
Abstract
PURPOSE Based on biomechanical anatomical studies, double-bundle reconstruction of the anterior cruciate ligament (ACL) was introduced to achieve better stability in the knee, particularly in respect of rotatory loads. An in vivo, computer-assisted, double-bundle (DB) ACL reconstruction is superior to a single-bundle (SB) ACL reconstruction at reducing rotatory, and AP laxities of the tibia at 20 degrees of knee flexion and also during the pivot shift test. METHODS The data of 63 patients who had ACL reconstruction were prospectively collected. Thirty-two patients had single-bundle reconstruction (SB group), and 31 received double-bundle reconstruction (DB group). The per-operative navigation system (Praxim ACL surgetics System) helped to search for a minimal anisometry profile of the grafts, which was favorable (graft loosened with flexion) in the anatomic area of ACL insertion and preventing any conflict between the graft and the femoral notch. The system also evaluated anteroposterior (AP) rotational stabilities and pivot shift. The value of the pivot shift was calculated from the values of the maximum rotation and AP translation obtained when performing the manoeuver before and after ACL reconstruction, comparing SB and DB reconstruction. RESULTS The post-operative AP displacement of the lateral compartment during the Lachman test was statistically reduced in DB group in comparison with SB group (5.1 ± 4.4 mm vs. 7.1 ± 3.2 mm, P = 0.04), whereas the AP displacements of the medial compartment were also reduced (3.4 ± 3.7 mm vs. 4.5 ± 2.6 mm, P = 0.15) but with no statistical significance. Internal and external rotations at 20° of knee flexion were lower in the DB group than in SB group with statistical significance (respectively, 13.2 ± 4.9° vs. 17.5 ± 4.0°, P < 0.001 and 9.1 ± 3.6° vs. 11.5 ± 3.5°, P = 0.01). During the pivot shift test, the post-operative AP maximal translation was statistically different in both groups: 4.5 ± 2.1 mm in DB group and 6.3 ± 2.7 mm in SB group (P = 0.01)), whereas the maximal rotation was not statistically different: 3.8 ± 2.5° in DB group and 3.4 ± 1.2° in SB group (n.s.). Therefore, Colombet's index was similar in DB group and SB group (respectively, 0.21 ± 0.16 and 0.17 ± 0.06, (n.s.)). CONCLUSIONS This study shows a significant intraoperative advantage in anterior and rotational stability for four-tunnel DB ACL reconstruction compared with SB ACL reconstruction. LEVEL OF EVIDENCE II.
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Maeyama A, Hoshino Y, Debandi A, Kato Y, Saeki K, Asai S, Goto B, Smolinski P, Fu FH. Evaluation of rotational instability in the anterior cruciate ligament deficient knee using triaxial accelerometer: a biomechanical model in porcine knees. Knee Surg Sports Traumatol Arthrosc 2011; 19:1233-8. [PMID: 21350960 DOI: 10.1007/s00167-010-1382-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 12/20/2010] [Indexed: 01/30/2023]
Abstract
PURPOSE To measure the acceleration in multiple directions of the rotational instability in ACL deficient models using porcine knees. METHODS Ten porcine knees were tested with ACL intact and tear models. The pivot shift test was performed manually, and the acceleration of the pivot shift phenomenon was recorded by the use of a triaxial accelerometer. Tests were repeated in four different ACL states: (1) intact; (2) partial AM deficient; (3) complete AM deficient, and (4) complete ACL (AM and PL) deficient. The acceleration in three directions and the magnitude of acceleration were measured to evaluate rotational instability and compare between different ACL conditions. RESULTS Significantly increased accelerations were observed in the complete deficient ACL model, while the partial ACL tear models demonstrated a slight increase without statistical significance. The accelerometer detected stepwise increases in the acceleration with the extent of ACL tear. Additionally, the PL bundle exhibited the largest contribution for rotational instability (80.4%) when compared with the AM (19.5%) bundles. CONCLUSION Triaxial accelerometer could serve as a quantitative evaluation of rotational instability. The present study demonstrated that PL bundle has the most important contribution for rotational instability (80.4%) when compared to IM bundle (0.01%) and AM bundle (19.5%) in porcine knee model.
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Affiliation(s)
- Akira Maeyama
- Department of Orthopaedic Surgery, School of Medicine, Fukuoka University, Fukuoka, Japan
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Lopomo N, Zaffagnini S, Signorelli C, Bignozzi S, Giordano G, Marcheggiani Muccioli GM, Visani A. An original clinical methodology for non-invasive assessment of pivot-shift test. Comput Methods Biomech Biomed Engin 2011; 15:1323-8. [PMID: 21728739 DOI: 10.1080/10255842.2011.591788] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Even if pivot-shift (PS) test has been clinically used to specifically detect anterior cruciate ligament (ACL) injury, the main problem in using this combined test has been yet associated with the difficulty of clearly quantifying its outcome. The goal of this study was to describe an original non-invasive methodology used to quantify PS test, highlighting its possible clinical reliability. The method was validated on 66 consecutive unilateral ACL-injured patients. A commercial triaxial accelerometer was non-invasively mounted on patient's tibia, the corresponding 3D acceleration was acquired during PS test execution and a set of specific parameters were automatically identified on the signal to quantify the test. PS test was repeated three times on both injured and controlateral limbs. Reliability of the method was found to be good (mean intra-rater intraclass correlation coefficient was 0.79); moreover, we found that ACL-deficient knees presented statistically higher values for the identified parameters--than the controlateral healthy limbs, averagely reporting also large effect size.
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Affiliation(s)
- Nicola Lopomo
- Laboratorio di Biomeccanica e Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy.
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Single-bundle patellar tendon versus non-anatomical double-bundle hamstrings ACL reconstruction: a prospective randomized study at 8-year minimum follow-up. Knee Surg Sports Traumatol Arthrosc 2011; 19:390-7. [PMID: 20668835 DOI: 10.1007/s00167-010-1225-y] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Accepted: 07/12/2010] [Indexed: 02/03/2023]
Abstract
PURPOSE The purpose of this study was to compare subjective, objective and radiographic outcome of the lateralized single-bundle bone-patellar tendon-bone autograft with a non-anatomical double-bundle hamstring tendons autograft anterior cruciate ligament (ACL) reconstruction technique at long-term follow-up. METHODS Seventy-nine non-consecutive randomized patients (42 men; 37 women) with unilateral ACL insufficiency were prospectively evaluated, before and after ACL reconstruction by means of the above-mentioned techniques, with a minimum follow-up of 8 years (range 8-10 years; mean 8.6 years). In the double-bundle hamstrings technique, we used one tibial and one femoral tunnel combined with one "over-the-top" passage, cortical staple's fixation and we left intact hamstrings' tibial insertion. Patients were evaluated subjectively and objectively, using IKDC score, Tegner level, manual maximum displacement test with KT-2000™ arthrometer. Radiographic evaluation was performed according to IKDC grading system, and re-intervention rate for meniscal lesions was also recorded. RESULTS The subjective and objective IKDC were similar in both groups while double-bundle hamstrings group showed significantly higher Tegner level (P = 0.0007), higher passive range of motion recovery (P = 0.0014), faster sport resumption (P = 0.0052), lower glide pivot-shift phenomenon (P = 0.0302) and lower re-intervention rate (P = 0.0116) compared with patellar tendon group. Radiographic evaluation showed significant lower objective degenerative changes in double-bundle hamstrings group at final follow-up (P = 0.0056). CONCLUSION Although both techniques provide satisfactory results, double-bundle ACL reconstruction shows better functional results, with a faster return to sport activity, a lower re-operation rate and lower degenerative knee changes.
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Motion within the unstable cervical spine during patient maneuvering: the neck pivot-shift phenomenon. ACTA ACUST UNITED AC 2011; 70:247-50; discussion 250-1. [PMID: 21217496 DOI: 10.1097/ta.0b013e3181fd0ebf] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cervical extrication collars are applied to millions of blunt trauma victims despite the lack of any evidence that a collar can protect against secondary injuries to the cervical spine. Cadaver studies support that in the presence of a dissociative injury, substantial motion can occur within the occipitocervical spine with collar application or during patient transfers. Little is known about the biomechanics of cervical stabilization; hence, it is difficult to develop and test improved immobilization strategies. MATERIALS Severe unstable injuries were created in seven fresh whole human cadavers. Rigid collars were applied with the body in a neutral position. Computed tomographic examinations were obtained before and after tilting the body or backboard as would be done during patient transport or to inspect the back. Relative displacements between vertebrae at the site of the injury were measured from the Computed tomographic examinations. The overall relative alignment between body and collar was assessed to understand the mechanisms that may facilitate motion at the injury site. RESULTS Intervertebral motion averaged 7.7 mm±6.8 mm in the axial plain and 2.9 mm±2.5 mm in the cranial-caudal direction. The rigid collars appeared to create pivot points where the collar contacts the head in the region under the ear and where the collar contacts the shoulders. DISCUSSION Rigid cervical collars appear to create pivot points that shift the center of rotation lateral to the spine and contribute to the intervertebral motions that were measured. Immobilization strategies that avoid these neck pivot-shift phenomena may help to reduce secondary injuries to the cervical spine. The whole cadaver model with simulation of patient maneuvers may provide an effective test method for cervical immobilization.
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Pelfort X, Torres R, Vilà G, Monllau J, Leal J, Hinarejos P, Puig L. Situación actual de la reconstrucción del ligamento cruzado anterior en nuestro país. Encuesta mediante formato electrónico. Rev Esp Cir Ortop Traumatol (Engl Ed) 2010. [DOI: 10.1016/j.recot.2010.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Pelfort X, Torres R, Vilà G, Monllau J, Leal J, Hinarejos P, Puig L. Update on Anterior Cruciate Ligament Reconstruction in Spain. Survey Using an Electronic Questionnaire. Rev Esp Cir Ortop Traumatol (Engl Ed) 2010. [DOI: 10.1016/s1988-8856(10)70248-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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