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Dadoo S, Ozbek EA, Nukuto K, Runer A, Keeling LE, Grandberg C, Kuroda R, Zaffagnini S, Karlsson J, Hughes JD, Irrgang JJ, Musahl V. What it takes to have a high-grade pivot shift-focus on bony morphology. Knee Surg Sports Traumatol Arthrosc 2023; 31:4080-4089. [PMID: 37410122 DOI: 10.1007/s00167-023-07472-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 05/30/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE Variations in femoral and tibial bony morphology have been associated with higher clinical grading and increased quantitative tibial translation, but not tibial acceleration, during the pivot shift test following anterior cruciate ligament (ACL) injury. The purpose of this study was to determine the impact of femoral and tibial bony morphology, including a measurement influenced by both parameters (the Lateral Tibiofemoral Articular Distance (LTAD)), on the degree of quantitative tibial acceleration during the pivot shift test and rates of future ACL injury. METHODS All patients who underwent primary ACL reconstruction from 2014 to 2019 by a senior orthopedic surgeon with available quantitative tibial acceleration data were retrospectively reviewed. All patients underwent a pivot shift examination under anesthesia with a triaxial accelerometer. Measurements of femoral and tibial bony morphology were performed by two fellowship-trained orthopedic surgeons using preoperative magnetic resonance imaging and lateral radiographs. RESULTS Fifty-one patients were included at a mean follow-up of 4.4 years. The mean quantitative tibial acceleration during the pivot shift was 13.8 m/s2 (range: 4.9-52.0 m/s2). A larger Posterior Condylar Offset Ratio (r = 0.30, p = 0.045), smaller medial-to-lateral width of the medial tibial plateau (r = - 0.29, p = 0.041), lateral tibial plateau (r = - 0.28, p = 0.042), and lateral femoral condyle (r = - 0.29, p = 0.037), and a decreased LTAD (r = - 0.53, p < 0.001) significantly correlated with increased tibial acceleration during the pivot shift. Linear regression analysis demonstrated an increase in tibial acceleration of 1.24 m/s2 for every 1 mm decrease in LTAD. Nine patients (17.6%) sustained ipsilateral graft rupture and 10 patients (19.6%) sustained contralateral ACL rupture. No morphologic measurements were associated with rates of future ACL injury. CONCLUSION Increased convexity and smaller bony morphology of the lateral femur and tibia were significantly associated with increased tibial acceleration during the pivot shift. Additionally, a measurement, termed the LTAD, was found to have the strongest association with increased tibial acceleration. Based on the results of this study, surgeons can utilize these measurements to preoperatively identify patients at risk of increased rotatory knee instability. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Sahil Dadoo
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Emre Anil Ozbek
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Orthopedic Surgery and Traumatology, University of Ankara, Ankara, Turkey
| | - Koji Nukuto
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Armin Runer
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Laura E Keeling
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Camila Grandberg
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica, Istituto Orthopedico Rizzoli, Bologna, Italy
| | - Jon Karlsson
- Department for Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jonathan D Hughes
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department for Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - James J Irrgang
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Volker Musahl
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department for Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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2
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McLeod KC, Barber FA. Pivot Shift Syndrome of the Knee. Sports Med Arthrosc Rev 2023; 31:34-40. [PMID: 37418172 DOI: 10.1097/jsa.0000000000000365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
The pivot shift test, in contrast to the Lachman or anterior drawer, is a manually subjective clinical test that simulates the injury mechanism. It is the most sensitive test to determine ACL insufficiency. This paper reviews the history, development, research, and treatment associated with the pivot shift phenomenon which is associated with tearing and loss of function of the knee anterior cruciate ligament. The pivot shift test most closely recapitulates what the symptomatic anterior cruciate ligament deficient patient feels is happening which is an abnormal translation and rotation of the injured joint during flexion or extension. The test is best conducted in the relaxed patient by applying knee flexion, tibial external rotation, and valgus stress. The pivot shift biomechanics and treatment measures are reviewed.
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Affiliation(s)
- Kevin C McLeod
- Baptist Health Specialty - Arkadelphia, Orthopedic Surgeon, 2915 Cypress Rd, Suite D, Arkadelphia, AR
| | - F Alan Barber
- Plano Orthopedic and Sports Medicine Center, Fellowship Director Emeritus, Plano, TX
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Yañez-Diaz R, Roby M, Silvestre R, Zamorano H, Vergara F, Sandoval C, Neira A, Yañez-Rojo C, De la Fuente C. Multiclass Support Vector Machine improves the Pivot-shift grading from Gerdy's acceleration resultant prior to the acute Anterior Cruciate Ligament surgery. Injury 2023:S0020-1383(23)00271-1. [PMID: 37003872 DOI: 10.1016/j.injury.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/02/2023] [Accepted: 03/13/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Rotatory laxity acceleration still lacks objective classification due to interval grading superposition, resulting in a biased pivot shift grading prior to the Anterior Cruciate Ligament (ACL) reconstruction. However, data analysis might help improve data grading in the operative room. Therefore, we described the improvement of the pivot-shift categorization in Gerdy's acceleration under anesthesia prior to ACL surgery using a support vector machine (SVM) classification, surgeon, and literature reference. METHODS Seventy-five patients (aged 30.3 ± 10.2 years, and IKDC 52.0 ± 16.5 points) with acute ACL rupture under anesthesia prior to ACL surgery were analyzed. Patients were graded with pivot-shift sign glide (+), clunk (++), and (+++) gross by senior orthopedic surgeons. At the same time, the tri-axial tibial plateau acceleration was measured. Categorical data were statistically described, and the accelerometry and categorical data were associated (α = 5%). A multiclass SVM kernel with the best accuracy trained by orthopedic surgeons and assisted from literature for missing data was compared with experienced surgeons and literature interval grading. The cubic SVM classifier achieved the best grading. RESULTS The intra-group proportions were different for each grading in the three compared strategies (p < 0.001). The inter-group proportions were different for all comparisons (p < 0.001). There were significant (p < 0.001) associations (Tau: 0.69, -0.28, and -0.50) between the surgeon and SVM, the surgeon and interval grading, and the interval and SVM, respectively. CONCLUSION The multiclass SVM classifier improves the acceleration categorization of the (+), (++), and (+++) pivot shift sign prior to the ACL surgery in agreement with surgeon criteria.
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Affiliation(s)
- Roberto Yañez-Diaz
- Traumatologia, Clinica MEDS, Santiago, Chile; Centro de Innovación, Clinica MEDS, Santiago Chile
| | - Matías Roby
- Traumatologia, Clinica MEDS, Santiago, Chile; Centro de Innovación, Clinica MEDS, Santiago Chile
| | - Rony Silvestre
- Centro de Innovación, Clinica MEDS, Santiago Chile; Carrera de Kinesiologia, Departamento de Ciencias de la Salud, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | | | | | | | - Alejandro Neira
- Escuela de Kinesiologia, Facultad de Medicina y Ciencias de la Salud, Universidad Mayor, Santiago, Chile
| | | | - Carlos De la Fuente
- Centro de Innovación, Clinica MEDS, Santiago Chile; Carrera de Kinesiologia, Departamento de Ciencias de la Salud, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile; Applied Neuromechanics Research Group, Universidade Federal do Pampa, Uruguaiana, RS, Brazil.
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El-Azab H, Moursy M, Mohamed MA, Elsayed M. A comparison of the outcomes of anterior curciate ligament reconstruction with large-size graft versus reconstruction with average-size graft combined with extraarticular tenodesis. Injury 2023; 54:976-982. [PMID: 36720663 DOI: 10.1016/j.injury.2023.01.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 01/01/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Many patients who have had anterior cruciate ligament (ACL) reconstruction (R) complain of instability, inability to return to previous levels of sports activity, and possible ACL graft failure. Graft size was discovered to be an important factor in lowering ACL failure rates. Also, extraarticular tenodesis decreases recurrent instability, A comparative study was done to compare the effect of graft size and lateral external tenodesis on the recurrence of instability after ACL-R. PATIENTS AND METHODS A Prospective Blinded Randomized Controlled study included 100 consecutive patients who underwent ACL-R with hamstring tendon grafts in our Hospital. The patients were allocated into two groups (Group A and B) with randomization; group A received ACL-R with a large-size ACL-graft diameter of 6 strands, and group B received ACL-R of 4 strands combined with lateral extraarticular tenodesis (LET) (Modified Lemaire). Each group had fifty patients. The follow-up time was two years. They were examined for graft failure, anterolateral rotatory instability with the pivot shift test, and clinical outcomes, which were evaluated with the International Knee Documentation Committee score (IKDC) both subjective and objective. RESULTS In this study; group A, graft failure occurred in three (6.3%) patients, a positive pivot shift test grade I was detected in eight (17.8%) patients, grade II in three (6.7%) patients, and grade III in one (2.2%) patient. The subjective IKDC score was 87.9 (± 7.19) points. The objective IKDC score was normal or nearly normal in 43 (93.4%) patients. In group B, one (2.1%) patient had graft failure, five (10.9%) had a positive pivot shift test grade I, one (2.1%) had a grade II, and no patient had a grade III. The subjective IKDC score was 91.9 (± 8.9) points. The objective IKDC score was normal or nearly normal in 44 (95.6%) patients. As regard the subjective IKDC score, there was a non-significant difference between both groups (p value = 0.465). CONCLUSION Both groups showed a low ACL-graft failure rate, low anterolateral rotatory instability, and a good clinical outcome. Although there was no significant difference in subjective IKDC score between both groups, the failure rate and anterolateral rotatory instability were significantly lower in the ACL-R (4 strands) with LET combination group than in the group with the large-diameter (6 strands) graft. LEVEL OF EVIDENCE Level 1; Randomized Comparative Study.
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Affiliation(s)
- Hossam El-Azab
- Department of Orthopaedics and Traumatology, Sohag Faculty of Medicine, Sohag University, Egypt.
| | - Mohamed Moursy
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Salzburg, Austria
| | - Mohamed A Mohamed
- Department of Orthopaedics and Traumatology, Sohag Faculty of Medicine, Sohag University, Egypt
| | - Moustafa Elsayed
- Department of Orthopaedics and Traumatology, Sohag Faculty of Medicine, Sohag University, Egypt
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Napier RJ, Feller JA, Devitt BM, McClelland JA, Webster KE, Thrush CSJ, Whitehead TS. Is the KiRA Device Useful in Quantifying the Pivot Shift in Anterior Cruciate Ligament-Deficient Knees? Orthop J Sports Med 2021; 9:2325967120977869. [PMID: 33553458 PMCID: PMC7841684 DOI: 10.1177/2325967120977869] [Citation(s) in RCA: 7] [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] [Received: 07/20/2020] [Accepted: 08/04/2020] [Indexed: 01/26/2023] Open
Abstract
Background: Various technologies have been developed to quantify the pivot shift, as it is regarded as a key indicator of anterolateral rotatory laxity of the knee. Purpose: To determine the usefulness of a commercially available triaxial accelerometer (Kinematic Rapid Assessment [KiRA]) in numerically quantifying the pivot shift in patients under anesthesia with an anterior cruciate ligament (ACL)–deficient knee. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Both knees of 50 patients (26 male [mean age, 30.4 years], 24 female [mean age, 26.6 years]) under anesthesia were assessed immediately before unilateral ACL reconstruction by an orthopaedic fellow and 1 of 3 experienced knee surgeons. The pivot-shift grade and 2 KiRA outputs (range of acceleration and slope of acceleration change) were compared. Results: The surgeon and fellow recorded the same pivot-shift grade for 45 of 50 patients (90%). Data from the 5 patients with no agreement and 1 patient with extreme outlying data were excluded from subsequent analysis. Using the KiRA range and slope data, the surgeon identified the injured knee in 74% and 76% of patients, respectively, while the fellow’s rate of injured knee identification was 74% and 80%, respectively. A correlation could be found only between pivot-shift grade and surgeon-derived range data (ρ = 0.40; P < .01) but not slope data or any fellow-derived outputs. Using the surgeon-derived range data, there was a significant difference between a grade 3 pivot (>5 m/s2) and a grade 1 or 2 pivot (<5 m/s2) (P = .01). Conclusion: Although a correlation between KiRA output data and pivot-shift grade was found when the device was used by an experienced surgeon, there was no correlation when used by a well-trained but less experienced orthopaedic fellow. Furthermore, the KiRA output data identified the ACL-deficient knee correctly in only 74% of patients. Although a threshold acceleration range value could be identified, above which the value was associated with a grade 3 pivot shift, this was dependent on the examiner, and distinction between other grades could not be made.
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Affiliation(s)
- Richard J Napier
- Orthopaedic Research Unit, Musgrave Park Hospital, Belfast, Northern Ireland
| | - Julian A Feller
- OrthoSport Victoria Research Unit, Epworth HealthCare, Melbourne, Australia.,School of Allied Health, La Trobe University, Melbourne, Australia
| | - Brian M Devitt
- OrthoSport Victoria Research Unit, Epworth HealthCare, Melbourne, Australia
| | | | - Kate E Webster
- School of Allied Health, La Trobe University, Melbourne, Australia
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Vaidya RK, Yoo CW, Lee J, Han HS, Lee MC, Ro DH. Quantitative assessment of the pivot shift test with smartphone accelerometer. Knee Surg Sports Traumatol Arthrosc 2020; 28:2494-2501. [PMID: 31840191 DOI: 10.1007/s00167-019-05826-3] [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: 04/28/2019] [Accepted: 12/10/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE The pivot shift (PS) test is commonly used to diagnose and evaluate the dynamic instability of the knee joint in cases of anterior cruciate ligament (ACL) tear. There is a need of a reliable and inexpensive tool which is easily available to measure PS objectively in a clinical setting. The purpose of this study was to evaluate the use of a smartphone, which is readily available, to assess the PS phenomenon. METHODS Seventeen patients with unilateral ACL-injured knees, undergoing ACL reconstruction, were enrolled in the study. PS was initially graded according to the International Knee Documentation Committee classification by two observers. The PS test was then performed by them in normal and injured knees under anaesthesia using a smartphone attached to Gerdy's tubercle. Acceleration changes during the PS test were recorded using the smartphone accelerometer application. Intra-observer and inter-observer reliability of the test among the two observers were evaluated. Acceleration changes were compared between the injured and normal knees, and also between the clinical grades of PS. Diagnostic utility of the smartphone accelerometer was examined by a receiver operating characteristic curve analysis. RESULTS Intra-observer and inter-observer reliability were high for the smartphone accelerometer. The acceleration change was higher in the ACL-injured knees than in normal knees. The mean acceleration change was 2.54 m/s2 (SD = 0.97) in ACL-injured knees and 0.73 m/s2 (SD = 0.19) in normal knees (p < 0.001). The mean acceleration change of Grade 1 knees was 1.89 m/s2 (SD = 0.57), and that of knees of Grade 2 and above were 2.99 m/s2 (SD = 0.95) (p < 0.05). Sensitivity was 94% and specificity was 100% for the acceleration change required to detect ACL injury, i.e., 1.24 m/s2. CONCLUSIONS The results show that a smartphone can be used to evaluate the PS quantitatively and reliably, in the diagnosis of ACL injury. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Rupesh Kumar Vaidya
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea
| | - Cheol Whan Yoo
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea
| | - Joonhee Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea
| | - Hyuk-Soo Han
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea
| | - Myung Chul Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea
| | - Du Hyun Ro
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea.
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7
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Lian J, Diermeier T, Meghpara M, Popchak A, Smith CN, Kuroda R, Zaffagnini S, Samuelsson K, Karlsson J, Irrgang JJ, Musahl V. Rotatory Knee Laxity Exists on a Continuum in Anterior Cruciate Ligament Injury. J Bone Joint Surg Am 2020; 102:213-220. [PMID: 31876642 DOI: 10.2106/jbjs.19.00502] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this investigation was to compare the magnitude of rotatory knee laxity in patients with a partial anterior cruciate ligament (ACL) tear, those with a complete ACL tear, and those who had undergone a failed ACL reconstruction. It was hypothesized that rotatory knee laxity would increase with increasing injury grade, with knees with partial ACL tears demonstrating the lowest rotatory laxity and knees that had undergone failed ACL reconstruction demonstrating the highest rotatory laxity. METHODS A prospective multicenter study cohort of 354 patients who had undergone ACL reconstruction between 2012 and 2018 was examined. All patients had both injured and contralateral healthy knees evaluated using standardized, preoperative quantitative pivot shift testing, determined by a validated, image-based tablet software application and a surface-mounted accelerometer. Quantitative pivot shift was compared with the contralateral healthy knee in 20 patients with partial ACL tears, 257 patients with complete ACL tears, and 27 patients who had undergone a failed ACL reconstruction. Comparisons were made using 1-way analysis of variance (ANOVA) with post hoc 2-sample t tests with Bonferroni correction. Significance was set at p < 0.05. RESULTS There were stepwise increases in side-to-side differences in quantitative pivot shift in terms of lateral knee compartment translation for patients with partial ACL tears (mean [and standard deviation], 1.4 ± 1.5 mm), those with complete ACL tears (2.5 ± 2.1 mm), and those who had undergone failed ACL reconstruction (3.3 ± 1.9 mm) (p = 0.01) and increases in terms of lateral compartment acceleration for patients with partial ACL tears (0.7 ± 1.4 m/s), those with complete ACL tears (2.3 ± 3.1 m/s), and those who had undergone failed ACL reconstruction (2.4 ± 5.5 m/s) (p = 0.01). A significant difference in lateral knee compartment translation was found when comparing patients with partial ACL tears and those with complete ACL tears (1.2 ± 2.1 mm [95% confidence interval (CI), 0.2 to 2.1 mm]; p = 0.02) and patients with partial ACL tears and those who had undergone failed ACL reconstruction (1.9 ± 1.7 mm [95% CI, 0.8 to 2.9 mm]; p = 0.001), but not when comparing patients with complete ACL tears and those who had undergone failed ACL reconstruction (0.8 ± 2.1 [95% CI, -0.1 to 1.6 mm]; p = 0.09). Increased lateral compartment acceleration was found when comparing patients with partial ACL tears and those with complete ACL tears (1.5 ± 3.0 m/s [95% CI, 0.8 to 2.3 m/s]; p = 0.0002), but not when comparing patients with complete ACL tears and those who had undergone failed ACL reconstruction (0.1 ± 3.4 m/s [95% CI, -2.2 to 2.4 m/s]; p = 0.93) or patients with partial ACL tears and those who had undergone failed ACL reconstruction (1.7 ± 4.2 m/s [95% CI, -0.7 to 4.0 m/s]; p = 0.16). An increasing lateral compartment translation of the contralateral, ACL-healthy knee was found in patients with partial ACL tears (0.8 mm), those with complete ACL tears (1.2 mm), and those who had undergone failed ACL reconstruction (1.7 mm) (p < 0.05). CONCLUSIONS A progressive increase in rotatory knee laxity, defined by side-to-side differences in quantitative pivot shift, was observed in patients with partial ACL tears, those with complete ACL tears, and those who had undergone failed ACL reconstruction. These results may be helpful when assessing outcomes and considering indications for the management of high-grade rotatory knee laxity. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jayson Lian
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Orthopaedic Surgery, Montefiore Medical Center, New York, NY
| | - Theresa Diermeier
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Orthopaedic Sport Medicine, Technical University Munich, Munich, Germany
| | - Mitchell Meghpara
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adam Popchak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Clair N Smith
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Stefano Zaffagnini
- Laboratorio di Biomeccanica e Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Kristian Samuelsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Jón Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - James J Irrgang
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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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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9
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Lian J, Novaretti JV, Sheean AJ, Patel NK, Whaley S, Popchak A, Musahl V. Static Lateral Tibial Plateau Subluxation Predicts High-Grade Rotatory Knee Laxity in Anterior Cruciate Ligament-Deficient Knees. Am J Sports Med 2019; 47:277-284. [PMID: 30525899 DOI: 10.1177/0363546518812435] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In anterior cruciate ligament-deficient (ACL-D) knees, injury pattern and bony morphologic features have been shown to influence both static anterior tibial subluxation relative to the femur and dynamic rotatory knee laxity. Therefore, the relationship between static anterior tibial subluxation and dynamic rotatory knee laxity was investigated. PURPOSE To determine whether static tibial subluxation as measured on magnetic resonance imaging (MRI) is associated with the grade of rotatory knee laxity in ACL-D knees. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Two-hundred fifty-eight knees underwent preoperative, image-guided assessment of lateral knee compartment translation during quantitative pivot shift (QPS). Subluxations of the medial and lateral tibial plateaus were measured on preoperative MRI in a subset of primary ACL-D knees meeting criteria for high-grade (QPS > 5.2 mm) and low-grade (QPS < 2.4 mm) rotatory laxity. Tibial subluxations on MRI were compared between patients with high- and low-grade rotatory laxity through use of pairwise t test and were analyzed via univariate and multivariate logistic regression. Significance was set at P < .05. RESULTS On MRI, greater anterior subluxation of the lateral tibial plateau was observed in patients with high-grade compared with low-grade rotatory knee laxity (4.5 mm vs 2.3 mm; P < .05). No similar relationship was observed for the medial tibial plateau (-0.9 mm vs -0.4 mm; P > .05). Univariate logistic regression demonstrated that static subluxation of the lateral tibial plateau was associated with high-grade rotatory knee laxity (odds ratio [OR], 1.2; P < .05). An optimal cutoff of 2.95 mm of static lateral tibial subluxation was associated with high-grade rotatory knee laxity (sensitivity, 75%; specificity, 63%). Lateral meniscal injury was the first variable entered into a multivariate regression analysis and proved to be most associated with high-grade rotatory knee laxity (OR, 6.8; P < .05). When lateral meniscal injury was excluded from multivariate regression analysis, static anterior subluxation of the lateral tibial plateau alone was associated with high-grade rotatory knee laxity (OR, 1.2; P < .05). CONCLUSION Data from this MRI study of two distinct rotatory knee laxity groups showed that static anterior subluxation of the lateral tibial plateau of 2.95 mm or greater was associated with high-grade rotatory knee laxity, and each millimeter increase of lateral tibial plateau subluxation was associated with a 1.2-fold odds of high-grade rotatory knee laxity. Anterior subluxation of the lateral tibial plateau on MRI was not independently associated with high-grade rotatory knee laxity in the presence of concomitant lateral meniscal injury. Static measurements made preoperatively may aid in predicting high-grade rotatory knee laxity and refining the indications for individualized knee surgery.
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Affiliation(s)
- Jayson Lian
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Albert Einstein College of Medicine, Bronx, New York, USA
| | - João V Novaretti
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Orthopaedics and Traumatology Sports Center (CETE), Department of Orthopaedics and Traumatology, Paulista School of Medicine (EPM), Federal University of São Paulo, São Paulo, Brazil
| | - Andrew J Sheean
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Neel K Patel
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sean Whaley
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam Popchak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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10
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Hoshino Y, Miyaji N, Nishida K, Nishizawa Y, Araki D, Kanzaki N, Kakutani K, Matsushita T, Kuroda R. The concomitant lateral meniscus injury increased the pivot shift in the anterior cruciate ligament-injured knee. Knee Surg Sports Traumatol Arthrosc 2019; 27:646-651. [PMID: 30310925 DOI: 10.1007/s00167-018-5209-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 10/04/2018] [Indexed: 01/26/2023]
Abstract
PURPOSE Concomitant meniscus injuries in the anterior cruciate ligament (ACL) have been suggested to exacerbate rotational laxity. However, the effect is supposed to be so small, if any, that some quantitative pivot-shift measurement is needed. The purpose of this prospective study was to determine the effect of meniscus tear on rotational laxity in ACL-deficient knees by an quantitative measurement. It was hypothesized that a concomitant meniscus tear, especially a lateral one, would induce greater pivot shift. METHODS Fifty-seven unilateral ACL-injured patients (26 men and 31 women, mean age: 24 ± 10 years) were included. The pivot-shift test was performed prior to ACL reconstruction, while a quantitative evaluation using an electromagnetic system to determine tibial acceleration and a clinical grading according to the IKDC were performed. Meniscus injuries were diagnosed arthroscopically, and concomitant meniscus tear was confirmed in 32 knees. RESULTS The clinical grade was not different between the ACL-injured knees of patients with and without meniscus tear (n.s.). Tibial acceleration did not show a statistical significant difference (meniscus-injured knees: 1.6 ± 1.1 m/s2 versus meniscus-intact knees: 1.2 ± 0.7 m/s2, n.s.). However, the subgroup analysis demonstrated that there was increased tibial acceleration in ACL-deficient knees with lateral meniscus tear (2.1 ± 1.1 m/s2, n = 13) compared with meniscus-intact knees (p < 0.05), whereas rotational laxity did not increase in the medial meniscus-injured and bilateral-injured knees (1.2 ± 0.9 m/s2, n = 12, n.s. and 1.4 ± 1.1 m/s2, n = 7, n.s., respectively). CONCLUSION A concomitant meniscus tear, especially a lateral meniscus tear, has a significant impact on rotational laxity in ACL-injured knees. When a large pivot shift is observed in the ACL-injured knee, a concomitant meniscus tear should be suspected and an aggressive treatment would be considered. Meniscus injuries should be inspected carefully when substantial pivot shift is encountered in ACL-injured knees. LEVEL OF EVIDENCE Diagnostic study, Level III.
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Affiliation(s)
- Yuichi Hoshino
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Nobuaki Miyaji
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kyohei Nishida
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | | | - Daisuke Araki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Noriyuki Kanzaki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kenichiro Kakutani
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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11
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Musahl V, Burnham J, Lian J, Popchak A, Svantesson E, Kuroda R, Zaffagnini S, Samuelsson K. High-grade rotatory knee laxity may be predictable in ACL injuries. Knee Surg Sports Traumatol Arthrosc 2018; 26:3762-3769. [PMID: 29931484 DOI: 10.1007/s00167-018-5019-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 06/07/2018] [Indexed: 01/26/2023]
Abstract
PURPOSE Lateral compartment acceleration and translation have been used to quantify rotatory knee laxity in the setting of anterior cruciate ligament (ACL) injury; however, their relationship remains elusive. The purpose of this study was to examine the correlation between lateral compartment acceleration and translation during pivot shift testing. It was hypothesized that a correlation would exist in ACL-injured and uninjured knees, irrespective of sex, but would be greatest in knees with combined ACL and lateral meniscus tear. METHODS Seventy-seven patients (34 females, 25.2 ± 9.0 years) undergoing primary single-bundle ACL reconstruction were prospectively enrolled in a 2-year study across four international centers. Patients underwent preoperative examination under anesthesia of the injured and uninjured knee using Image Analysis software and surface mounted accelerometer. RESULTS A moderate correlation between lateral compartment acceleration and translation was observed in ACL-injured knees [ρ = 0.36, p < 0.05), but not in uninjured knees (ρ = 0.17, not significant (n.s.)]. A moderate correlation between acceleration and translation was demonstrated in ACL-injured knees with lateral meniscus tears (ρ = 0.53, p < 0.05), but not in knees with isolated ACL-injury (ρ = 0.32, n.s.), ACL and medial meniscus tears (ρ = 0.14, n.s.), or ACL and combined medial and lateral meniscus tears (ρ = 0.40, n.s.). A moderate correlation between acceleration and translation was seen in males (ρ = 0.51, p < 0.05), but not in females (ρ = 0.21, n.s.). Largest correlations were observed in males with ACL and lateral meniscus tears (ρ = 0.75, p < 0.05). CONCLUSION Lateral compartment acceleration and translation were moderately correlated in ACL-injured knees, but largely correlated in males with combined ACL and lateral meniscus tears. ACL and lateral meniscus injury in males might, therefore, be suspected when both lateral compartment acceleration and translation are elevated. Surgeons should have a greater degree of suspicion for high-grade rotatory knee laxity in ACL-injured males with concomitant lateral meniscus tears. Future studies should investigate how these two distinct components of rotatory knee laxity-lateral compartment acceleration and translation-are correlated with patient outcomes and affected by ACL surgery. LEVEL OF EVIDENCE Prospective cohort study; Level of evidence II.
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Affiliation(s)
- Volker Musahl
- UPMC Center for Sports Medicine, Department of Orthopaedic Surgery, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA, 15203, USA.
| | - Jeremy Burnham
- UPMC Center for Sports Medicine, Department of Orthopaedic Surgery, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA, 15203, USA
| | - Jayson Lian
- UPMC Center for Sports Medicine, Department of Orthopaedic Surgery, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA, 15203, USA.,Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Adam Popchak
- UPMC Center for Sports Medicine, Department of Orthopaedic Surgery, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA, 15203, USA
| | - Eleonor Svantesson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University, Kobe, Japan
| | - Stefano Zaffagnini
- Laboratorio di Biomeccanica e Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopedics, Sahlgrenska University Hospital, Mölndal, Sweden
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Marcheggiani Muccioli GM, Signorelli C, Grassi A, Sarsina TRD, Raggi F, Carbone G, Macchiarola L, Vaccari V, Zaffagnini S. In-vivo pivot-shift test measured with inertial sensors correlates with the IKDC grade. J ISAKOS 2018. [DOI: 10.1136/jisakos-2017-000167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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13
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Comparison of quantitative evaluation between cutaneous and transosseous inertial sensors in anterior cruciate ligament deficient knee: A cadaveric study. J Orthop Sci 2017; 22:874-879. [PMID: 28559103 DOI: 10.1016/j.jos.2017.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 03/31/2017] [Accepted: 04/26/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Recently several authors have reported on the quantitative evaluation of the pivot-shift test using cutaneous fixation of inertial sensors. Before utilizing this sensor for clinical studies, it is necessary to evaluate the accuracy of cutaneous sensor in assessing rotational knee instability. To evaluate the accuracy of inertial sensors, we compared cutaneous and transosseous sensors in the quantitative assessment of rotational knee instability in a cadaveric setting, in order to demonstrate their clinical applicability. METHODS Eight freshly frozen human cadaveric knees were used in this study. Inertial sensors were fixed on the tibial tuberosity and directly fixed to the distal tibia bone. A single examiner performed the pivot shift test from flexion to extension on the intact knees and ACL deficient knees. The peak overall magnitude of acceleration and the maximum rotational angular velocity in the tibial superoinferior axis was repeatedly measured with the inertial sensor during the pivot shift test. Correlations between cutaneous and transosseous inertial sensors were evaluated, as well as statistical analysis for differences between ACL intact and ACL deficient knees. RESULTS Acceleration and angular velocity measured with the cutaneous sensor demonstrated a strong positive correlation with the transosseous sensor (r = 0.86 and r = 0.83). Comparison between cutaneous and transosseous sensor indicated significant difference for the peak overall magnitude of acceleration (cutaneous: 10.3 ± 5.2 m/s2, transosseous: 14.3 ± 7.6 m/s2, P < 0.01) and for the maximum internal rotation angular velocity (cutaneous: 189.5 ± 99.6 deg/s, transosseous: 225.1 ± 103.3 deg/s, P < 0.05), but no significant difference for the maximum external rotation angular velocity (cutaneous: 176.1 ± 87.3 deg/s, transosseous: 195.9 ± 106.2 deg/s, N.S). CONCLUSIONS There is a positive correlation between cutaneous and transosseous inertial sensors. Therefore, this study indicated that the cutaneous inertial sensors could be used clinically for quantifying rotational knee instability, irrespective of the location of utilization.
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14
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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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15
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Kopf S, Musahl V, Perka C, Kauert R, Hoburg A, Becker R. The influence of applied internal and external rotation on the pivot shift phenomenon. Knee Surg Sports Traumatol Arthrosc 2017; 25:1106-1110. [PMID: 28194500 DOI: 10.1007/s00167-017-4429-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 01/04/2017] [Indexed: 01/12/2023]
Abstract
PURPOSE The pivot shift test is performed in different techniques and the rotation of the tibia seems to have a significant impact on the amount of the pivot shift phenomenon. It has been hypothesised that external rotation will increase the phenomenon due to less tension at the iliotibial band in knee extension. METHODS Twenty-four patients with unilateral anterior cruciate ligament insufficiency were included prospectively. The pivot shift test was performed bilaterally in internal and external tibial rotation under general anaesthesia. Knee motion was captured using a femoral and a tibial inertial sensor. The difference between positive and negative peak values in Euclidean norm of acceleration was calculated to evaluate the amount of the pivot shift phenomenon. RESULTS The pivot shift phenomenon was significantly increased in patients with ACL insufficiency when the test was performed in external [mean 5.2 ms- 2 (95% CI 4.3-6.0)] compared to internal tibial rotation [mean 4.4 ms- 2 (95% CI 3.5-5.4)] (p = 0.002). In healthy, contralateral knees did not show any difference between external [mean 4.0 ms- 2 (95% CI 3.3-4.7)] and internal tibial rotation [mean 4.0 ms- 2 (95% CI 3.4-4.6)] (ns). CONCLUSIONS The pivot shift phenomenon was increased with external rotation in ACL-insufficient knees, and therefore, one should perform the pivot shift test, rather, in external rotation to easily evoke the, sometimes difficult to detect, pivot shift phenomenon. LEVEL OF EVIDENCE I (diagnostic study).
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Affiliation(s)
- Sebastian Kopf
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carsten Perka
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Ralf Kauert
- Institute of Micro and Sensor Systems, Otto-von-Guericke-University, Magdeburg, Germany
| | - Arnd Hoburg
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Roland Becker
- Department of Orthopaedic and Traumatology, Medical School Theodor Fontane, Brandenburg, Germany
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16
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Burnham JM, Herbst E, Pauyo T, Pfeiffer T, Johnson DL, Fu FH, Musahl V. Technical Considerations in Revision Anterior Cruciate Ligament (ACL) Reconstruction for Operative Techniques in Orthopaedics. ACTA ACUST UNITED AC 2017; 27:63-69. [PMID: 28989265 DOI: 10.1053/j.oto.2017.01.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
As the incidence of anterior cruciate ligament (ACL) reconstruction continues to increase, the rate of revision surgery continues to climb. Revision surgery has inherent challenges that must be addressed in order to achieve successful results. The cause of the primary ACL reconstruction failure should be determined, and careful preoperative planning should be performed to address the cause(s) of failure. Each patient undergoing revision surgery should undergo a thorough history and physical examination, receive full length alignment radiographs, lateral radiographs, 45-degree flexion weight-bearing postero-anterior radiographs, and patellofemoral radiographs. 3-dimensional computed topography (CT) scan should be performed to assess tunnel position and widening. Magnetic resonance imaging (MRI) should be used to assess for intra-articular soft tissue pathology. Meniscal tears, meniscal deficiency, anterolateral capsule injuries, bony morphology, age, activity level, connective tissue diseases, infection, graft choice, and tunnel position can all impact the success of ACL reconstruction surgery. Meniscal lesions should be repaired, and in cases of persistent rotatory instability, extra-articular procedures may be indicated. Furthermore, osteotomies may be needed to correct malalignment or excess posterior tibial slope. Depending on the placement and condition of the original femoral and tibial tunnels, revision surgery may be performed in a single procedure or in a staged manner. In most cases, the surgery can be performed in one procedure. Regardless, the surgeon must communicate with the patient openly regarding the implications of revision ACL surgery and the treatment plan should be developed in a shared fashion between the surgeon and the patient.
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Affiliation(s)
- Jeremy M Burnham
- Department of Orthopaedic Surgery, UPMC Center for Sports Medicine, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA 15203, USA
| | - Elmar Herbst
- Department of Orthopaedic Surgery, UPMC Center for Sports Medicine, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA 15203, USA
| | - Thierry Pauyo
- Department of Orthopaedic Surgery, UPMC Center for Sports Medicine, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA 15203, USA
| | - Thomas Pfeiffer
- Department of Orthopaedic Surgery, UPMC Center for Sports Medicine, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA 15203, USA
| | - Darren L Johnson
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky Medical Center, 740 S. Limestone, K401, Lexington, KY 40536 USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, UPMC Center for Sports Medicine, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA 15203, USA
| | - 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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17
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Debandi A, Maeyama A, Hoshino Y, Asai S, Goto B, Smolinski P, Fu FH. The Influence of Knee Flexion Angle for Graft Fixation on Rotational Knee Stability During Anterior Cruciate Ligament Reconstruction: A Biomechanical Study. Arthroscopy 2016; 32:2322-2328. [PMID: 27189870 DOI: 10.1016/j.arthro.2016.03.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 02/21/2016] [Accepted: 03/11/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate the effect of knee flexion angle for hamstring graft fixation, full extension (FE), or 30°, on acceleration of the knee motion during pivot-shift testing after either anatomic or nonanatomic anterior cruciate ligament (ACL) reconstruction using triaxial accelerometry. METHODS Two types of ACL reconstructions (anatomic and nonanatomic) using 2 different angles of knee flexion during graft fixation (FE and 30°) were performed on 12 fresh-frozen human knees making 4 groups: anatomic-FE, anatomic-30°, nonanatomic-FE, and nonanatomic-30°. Manual pivot-shift testing was performed at ACL-intact, ACL-deficient, and ACL-reconstructed conditions. Three-dimensional acceleration of knee motion was recorded using a triaxial accelerometer. RESULTS The anatomic-30° group showed the smallest overall magnitude of acceleration among the ACL-reconstructed groups (P = .0039). There were no significant differences among the anatomic-FE group, the nonanatomic-FE group, and the nonantomic-30° group (anatomic-FE vs nonanatomic-FE, P = .1093; anatomic-FE vs nonanatomic-30°, P = .8728; and nonanatomic-FE vs nonanatomic-30°, P = .1093). After ACL transection, acceleration was reduced by ACL reconstruction with the exception of the nonanatomic-FE group that did not show a significant difference when compared with the ACL-deficient (P = .4537). CONCLUSIONS The anatomic ACL reconstruction with the graft fixed at 30° of knee flexion better restored rotational knee stability compared with FE. An ACL graft fixed with the knee at FE in anatomic position did not show a significant difference compared with the nonanatomic ACL reconstructions. CLINICAL RELEVANCE Knee flexion angle at the time of graft fixation for ACL reconstruction can be considered to maximize the rotational knee stability.
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Affiliation(s)
- Aníbal Debandi
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Akira Maeyama
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Shigehiro Asai
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Bunsei Goto
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Patrick Smolinski
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A.; Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A.; Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A..
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18
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Abstract
Motion at the knee joint is a complex mechanical phenomenon. Stability is provided by a combination of static and dynamic structures that work in concert to prevent excessive movement or instability that is inherent in various knee injuries. The anterior cruciate ligament (ACL) is a main stabilizer of the knee, providing both translational and rotatory constraint. Despite the high volume of research directed at native ACL function, pathogenesis and surgical reconstruction of this structure, a gold standard for objective quantification of injury and subsequent repair, has not been demonstrated. Furthermore, recent studies have suggested that novel anatomic structures may play a significant role in knee stability. The use of biomechanical principles and testing techniques provides essential objective/quantitative information on the function of bone, ligaments, joint capsule, and other contributing soft tissues in response to various loading conditions. This review discusses the principles of biomechanics in relation to knee stability, with a focus on the objective quantification of knee stability, the individual contributions of specific knee structures to stability, and the most recent technological advances in the biomechanical evaluation of the knee joint.
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Affiliation(s)
- Jason P Zlotnicki
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Orthopaedic Robotics Laboratory, University of Pittsburgh, 408 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA, 15219, USA
| | - Jan-Hendrik Naendrup
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Orthopaedic Robotics Laboratory, University of Pittsburgh, 408 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA, 15219, USA
| | - Gerald A Ferrer
- Orthopaedic Robotics Laboratory, University of Pittsburgh, 408 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA, 15219, USA
- Department of Bioengineering, University of Pittsburgh, 300 Technology Drive, Pittsburgh, PA, 15219, USA
| | - Richard E Debski
- Orthopaedic Robotics Laboratory, University of Pittsburgh, 408 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA, 15219, USA.
- Department of Bioengineering, University of Pittsburgh, 300 Technology Drive, Pittsburgh, PA, 15219, USA.
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Zens M, Niemeyer P, Bernstein A, Feucht MJ, Kühle J, Südkamp NP, Woias P, Mayr HO. Novel approach to dynamic knee laxity measurement using capacitive strain gauges. Knee Surg Sports Traumatol Arthrosc 2015; 23:2868-75. [PMID: 26328800 DOI: 10.1007/s00167-015-3771-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 08/21/2015] [Indexed: 01/26/2023]
Abstract
PURPOSE Knee joint laxities are observed in patients after severe trauma to the joint, resulting in ligament tears. Specifically, injuries to the anterior cruciate ligament may cause a significant instability. The degree of these laxities is essential in diagnostics and may affect which treatment option is suggested. METHODS Polydimethylsiloxane (PDMS) strain gauges are proposed as a non-invasive, highly accurate and easy-to-use measurement method to quantify anterolateral and rotational laxities of the knee joint during active and passive motion. In this work, proof-of-concept measurements and a prototype of the proposed device are displayed. The measurements were taken using a knee test rig, which has specifically been designed for this purpose. This apparatus allows the simulation of isolated knee joint instabilities with a motor-controlled model of a human knee. RESULTS The absolute sensitivity [Formula: see text] of an exemplary sensor was determined to be 2.038 [Formula: see text]; the relative sensitivity [Formula: see text] was 1.121 [Formula: see text]. Optimal positions of sensors to capture bone-to-bone displacement as projected displacement on the skin were identified. CONCLUSION PDMS strain gauges are capable of measuring bone-to-bone displacements on the skin. We present an experimental in vitro study using an artificial knee test rig to simulate knee joint laxities and display the feasibility of our novel measurement approach.
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Affiliation(s)
- Martin Zens
- Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, 79106, Freiburg, Germany.
- Department of Microsystems Engineering (IMTEK), Albert-Ludwigs-Universität Freiburg, Georges-Koehler-Allee 102, 79110, Freiburg, Germany.
| | - Philipp Niemeyer
- Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, 79106, Freiburg, Germany
| | - Anke Bernstein
- Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, 79106, Freiburg, Germany
| | - Matthias J Feucht
- Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, 79106, Freiburg, Germany
| | - Jan Kühle
- Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, 79106, Freiburg, Germany
| | - Norbert P Südkamp
- Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, 79106, Freiburg, Germany
| | - Peter Woias
- Department of Microsystems Engineering (IMTEK), Albert-Ludwigs-Universität Freiburg, Georges-Koehler-Allee 102, 79110, Freiburg, Germany
| | - Herrmann O Mayr
- Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, 79106, Freiburg, Germany
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20
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Sena MP, DellaMaggioria R, Lotz JC, Feeley BT. A mechanical pivot-shift device for continuously applying defined loads to cadaveric knees. Knee Surg Sports Traumatol Arthrosc 2015; 23:2900-8. [PMID: 26359176 DOI: 10.1007/s00167-015-3775-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 08/25/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Current techniques to study the biomechanics of the pivot-shift utilize either static or poorly defined loading conditions. Here, a novel mechanical pivot-shift device that continuously applies well-defined loads to cadaveric knees is characterized and validated against the manual pivot-shift. METHODS Six fresh-frozen human lower limb specimens were potted at the femur, mounted on a hinged testing base, and fitted with the mechanical device. Five mechanical and manual pivot-shift tests were performed on each knee by two examiners before and after transecting the ACL. Three-dimensional kinematics (anterior and internal-rotary displacements, and posterior and external-rotary velocities) and kinetics (forces and moments applied to the tibia by the device) were recorded using an optical navigation system and 6-axis load cell. Analysis of variance and Bland-Altman statistics were used to gauge repeatability within knees, reproducibility between knees, agreement between the mechanical and manual test methods, and agreement between examiners. RESULTS The forces and moments applied by the device were continuous and repeatable/reproducible to within 4/10 % of maximum recorded values. Kinematic variables (excluding external-rotary velocity) were qualitatively and quantitatively similar to manual pivot-shift kinematics, and were more repeatable and reproducible. CONCLUSION The presented device induces pivot-shift-like kinematics by applying highly repeatable three-dimensional loads to cadaver knees. It is based on a simple mechanical principle and designed using easily obtainable components. Consequently, the device enables orthopaedic biomechanists to easily and reliably quantify the effect of ACL injury and reconstruction on pivot-shift kinematics.
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Affiliation(s)
- Mark P Sena
- Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, University of California, San Francisco 1500 Owens Ave, San Francisco, CA, 94158, USA
| | - Ryan DellaMaggioria
- Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, University of California, San Francisco 1500 Owens Ave, San Francisco, CA, 94158, USA
- Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jeffrey C Lotz
- Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, University of California, San Francisco 1500 Owens Ave, San Francisco, CA, 94158, USA
| | - Brian T Feeley
- Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, University of California, San Francisco 1500 Owens Ave, San Francisco, CA, 94158, USA.
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21
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Labbé DR, Li D, Grimard G, de Guise JA, Hagemeister N. Quantitative pivot shift assessment using combined inertial and magnetic sensing. Knee Surg Sports Traumatol Arthrosc 2015; 23:2330-2338. [PMID: 24832695 DOI: 10.1007/s00167-014-3056-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 05/02/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of the study was to demonstrate the feasibility of a new measurement system using micro-electromechanical systems (MEMS)-based sensors for quantifying the pivot shift phenomenon. METHODS The pivot shift test was performed on 13 consecutive anterior cruciate ligament-deficient subjects by an experienced examiner while femur and tibia kinematics were recorded using two inertial sensors each composed of an accelerometer, gyroscope and magnetometer. The gravitational component of the acquired data was removed using a novel method for estimating sensor orientations. Correlation between the clinical pivot shift grade and acceleration and velocity parameters was measured using Spearman's rank correlation coefficients. RESULTS The pivot shift phenomenon was best characterized as a drop in femoral acceleration observed at the time of reduction. The correlation between the femoral acceleration drop and the clinical grade was shown to be very strong (r = 0.84, p < 0.0001). CONCLUSIONS The present study demonstrates the feasibility of quantifying the pivot shift using MEMS-based sensors and removing the gravitational component of acceleration using an estimation of sensor orientation for improved correlation to the clinical grade.
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Affiliation(s)
- David R Labbé
- Laboratoire de recherche en imagerie et orthopédie (LIO), Centre de recherche du Centre hospitalier de l'Université de Montréal (CHUM), Tour Viger, 900, rue Saint-Denis, Local R11.326, Montreal, QC, H2X 0A9, Canada. .,École de technologie supérieure, Montreal, Canada.
| | - Di Li
- Laboratoire de recherche en imagerie et orthopédie (LIO), Centre de recherche du Centre hospitalier de l'Université de Montréal (CHUM), Tour Viger, 900, rue Saint-Denis, Local R11.326, Montreal, QC, H2X 0A9, Canada.,École de technologie supérieure, Montreal, Canada
| | - Guy Grimard
- Centre hospitalier universitaire Ste-Justine, Montreal, Canada
| | - Jacques A de Guise
- Laboratoire de recherche en imagerie et orthopédie (LIO), Centre de recherche du Centre hospitalier de l'Université de Montréal (CHUM), Tour Viger, 900, rue Saint-Denis, Local R11.326, Montreal, QC, H2X 0A9, Canada.,École de technologie supérieure, Montreal, Canada
| | - Nicola Hagemeister
- Laboratoire de recherche en imagerie et orthopédie (LIO), Centre de recherche du Centre hospitalier de l'Université de Montréal (CHUM), Tour Viger, 900, rue Saint-Denis, Local R11.326, Montreal, QC, H2X 0A9, Canada.,École de technologie supérieure, Montreal, Canada
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22
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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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23
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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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24
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van Eck CF, Fu FH. Anatomic anterior cruciate ligament reconstruction using an individualized approach. ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2014. [DOI: 10.1016/j.asmart.2013.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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25
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van Eck CF, Loopik M, van den Bekerom MP, Fu FH, Kerkhoffs GMMJ. Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of instrumented knee laxity tests. Knee Surg Sports Traumatol Arthrosc 2013; 21:1989-97. [PMID: 23073818 DOI: 10.1007/s00167-012-2246-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 10/05/2012] [Indexed: 02/07/2023]
Abstract
PURPOSE The aims of this meta-analysis were to determine the sensitivity and specificity of the KT 1000 Arthrometer, Stryker Knee Laxity Tester and Genucom Knee Analysis System for ACL rupture. It was hypothesized that the KT 1000 test is the most sensitive and specific. Secondly, it was hypothesized that the sensitivity and specificity of the KT 1000 arthrometer increase when the amount of Newton force is increased. METHODS An electronic database search was performed using MEDLINE and EMBASE. All cross-sectional and cohort studies comparing one or more instrumented examination tests for diagnosing acute complete ACL rupture in living human subjects to an accepted reference standard such as arthroscopy, arthrotomy and MRI were included. RESULTS The sensitivity of the KT 1000 Arthrometer with 69 N was 0.54. With 89 N, the sensitivity was 0.78 and the specificity 0.92, and with maximum manual force, the sensitivity was 0.93 and the specificity 0.93. For the Stryker Knee Laxity Tester, the sensitivity was 0.82 and the specificity 0.90. And for the Genucom Knee Analysis System, the sensitivity was 0.74 and the specificity 0.82. CONCLUSION The KT Arthrometer performed with maximum manual force has the highest sensitivity, specificity, accuracy and positive predictive value for diagnosing ACL rupture. LEVEL OF EVIDENCE Meta-analysis, level I.
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Affiliation(s)
- Carola F van Eck
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufman building suite 1011, Pittsburgh, PA 15213, USA.
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26
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Suero EM, Njoku IU, Voigt MR, Lin J, Koenig D, Pearle AD. The role of the iliotibial band during the pivot shift test. Knee Surg Sports Traumatol Arthrosc 2013; 21:2096-100. [PMID: 23104167 DOI: 10.1007/s00167-012-2257-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 10/16/2012] [Indexed: 01/13/2023]
Abstract
PURPOSE Several studies have suggested that the iliotibial (IT) band plays a role in knee laxity and that it may affect the magnitude of the pivot shift observed. However, the extent of the role played by the IT band, as well as its mechanism of action, is not currently known. This cadaveric study aimed to quantify the effect of the IT band and the hip abduction angle on the magnitude of anterior tibial translation (ATT) during the pivot shift. METHODS Six fresh-frozen hip-to-toes specimens were used. Serial sectioning of the anterior cruciate ligament (ACL) and the IT band was performed. Lachman and mechanized pivot shift manoeuvres were employed at each stage, and ATT of the lateral and medial compartments was measured using navigation. Three hip abduction angles were tested for each condition: 0°, 15° and 30°. RESULTS Sequential sectioning of the ACL and the IT band resulted in a significant increase in ATT in both the lateral (Intact = 0 ± 0.5 mm; ACL deficient = 8.1 ± 0.2 mm; ACL + IT deficient = 10.8 ± 0.3 mm) and medial (Intact = 6.7 ± 0.4 mm; ACL deficient = 8.4 ± 0.3 mm; ACL + IT deficient = 9.9 ± 0.3 mm) compartments. No significant increase in ATT was observed after changing the hip abduction angle at each stage. CONCLUSIONS An increase in the magnitude of the pivot shift and the Lachman was observed as the constraint of the IT band was removed. Additionally, it was shown that the hip abduction angle at which the pivot shift test was performed did not significantly affect the magnitude of ATT in this cadaveric model.
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Affiliation(s)
- Eduardo M Suero
- Computer Assisted Surgery Center, Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E 70th St., New York, NY 10021, USA
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27
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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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Sena M, Chen J, Dellamaggioria R, Coughlin DG, Lotz JC, Feeley BT. Dynamic evaluation of pivot-shift kinematics in physeal-sparing pediatric anterior cruciate ligament reconstruction techniques. Am J Sports Med 2013; 41:826-34. [PMID: 23408589 DOI: 10.1177/0363546513476470] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Conventional transphyseal anterior cruciate ligament (ACL) reconstruction techniques in skeletally immature patients have been questioned because of potential physeal injuries. Consequently, multiple alternative reconstruction options have been described to restore stability while sparing the physes in the skeletally immature patient. HYPOTHESIS All pediatric reconstruction techniques will restore knee stability to intact levels, and the knee stability index (KSI) will discriminate stability patterns between reconstruction techniques. STUDY DESIGN Controlled laboratory study. METHODS A novel mechanical pivot-shift device (MPSD) that consistently applies dynamic loads to cadaveric knees was used to study the effect of different physeal-sparing ACL reconstruction techniques on knee stability. Six adult cadaveric fresh-frozen knees were used. All knees were tested with 3 physeal-sparing reconstruction techniques: all epiphyseal (AE), transtibial over the top (TT), and iliotibial band (ITB). The MPSD was used to consistently perform a simulated pivot-shift maneuver. Tibial anterior displacement (AD), internal rotation (IR), posterior translational velocity (PTV), and external rotational velocity (ERV) were recorded using an Optotrak navigation system. The KSI (score range, 0-100; 0 = intact knee) was quantified using a regression analysis of AD, IR, PTV, and ERV. Repeated-measures analysis of variance and logistic regression were used for comparison of kinematics and derivation of KSI coefficients, respectively. RESULTS ACL deficiency resulted in an increase of 20% to 115% in all primary stability measures tested compared with the ACL-intact state. All reconstructions resulted in a decrease in ADmax and IRmax as well as PTVmax and ERVmax to within intact ranges, indicating that all reconstructions do improve stability compared with the ACL-deficient state. The ITB reconstruction overconstrained AD and IR by 38% and 52%, respectively. The mean (±SD) KSI for the ACL-deficient state was 61.7 ± 22.2 (range, 47-100), while the ITB reconstruction had a mean KSI of 0.82 ± 24.0 (range, -24 to 35), the TT reconstruction had a mean KSI of 13.3 ± 8.9 (range, 0.3-23), and the AE reconstruction had a mean KSI of -4.0 ± 15.2 (range, -24 to 14). The KSI was not significantly different between reconstructions, and all were significantly lower than the ACL-deficient state (P < .0001). CONCLUSION Although all reconstruction techniques tested were able to partially stabilize an ACL-deficient knee, the AE reconstruction was most effective in restoring native knee kinematics under dynamic loading conditions that mimic the pivot-shift test. CLINICAL RELEVANCE This study provides orthopaedic surgeons with objective dynamic rotational data on the ability of physeal-sparing ACL reconstructions to better determine the ideal technique for ACL construction in skeletally immature patients.
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Affiliation(s)
- Mark Sena
- Department of Orthopaedic Surgery, University of California, San Francisco, CA 94158, USA
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30
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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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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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