The maximal anterior subluxa tion of the lateral tibial plateau varied from 14 to 19.8 mm (mean, 17.2 ± 2.0 mm), whereas anterior sublux ation of the medial tibial plateau ranged from 6 to 16.9 mm (mean, 11.2 ± 3.3 mm). It has been suggested that the anterolateral ligament (ALL) is an important anterolateral stabilizer of the knee joint which functions to prevent anterolateral subluxation and anterior subluxation at certain flexion angles in the knee. Classification of knee ligament instabilities. The magnitude of ante rior subluxation of each plateau depended upon the examiner's technique. An increased posterior tibial slope was found to predict high-grade rotatory knee laxity, while a smaller medial tibial depth and increased lateral tibial plateau slope have been associated with increased risk of ACL injuries [29, 78, 79]. d demonstrates the final anatomic ACL reconstruction. Contact us if you experience any difficulty logging in. Rotatory knee instability in the ACL-deficient knee is an abnormal, complex three-dimensional motion comprised of translation and rotation along a helical axis [11, 16]. Each examiner performed his pivot shift test. The pivot shift test is the most specific clinical test for ACL injury, and works by assessing kinematic dysfunction of the ACL-deficient knee during simulation of a rotatory knee injury mechanism [5, 32, 40, 87]. Volker Musahl. PubMed Central  Many structures play a role in rotatory knee stability, but similar to the nomenclature of structures, there remains controversy as to the relative role that each structure plays in maintaining rotational integrity. Am J Sports Med 32:337–345, Slocum DB, James SL, Larson RL, Singer KM (1976) Clinical test for anterolateral rotary instability of the knee. Knee Surg Sports Traumatol Arthrosc 21:975–980, Hoshino Y, Kuroda R, Nagamune K, Araki D, Kubo S, Yamaguchi M et al (2012) Optimal measurement of clinical rotational test for evaluating anterior cruciate ligament insufficiency. The disadvantages of the navigated measurement methods are their limited availability, as they cannot be used outside the operating room, are invasive, and are expensive, making them impractical in the clinical setting [16, 32]. The tibial and femoral bony landmarks were digitized to determine the positions of the medial and lateral tibial plateaus in reference to the femoral condyles during the pivot shift tests. Bach BR, Warren RF, Wickiewicz TL The pivot shift phenomenon. The anterolateral stabilizing structures of the knee have been referred to by many names, including the mid-third lateral capsular layer, anterior oblique band of the fibular collateral ligament, the capsulo-osseous layer of the iliotibial band (ITB), the anterolateral ligament (ALL), the anterolateral capsule, and the anterolateral complex [28, 30] (Fig. A 1 cm × 8 cm strip of iliotibial band is harvested and detached proximally. Orthop Traumatol Surg Res 98:S201–S210, Dickens CJF, Kilcoyne CK, Kluk CM, Rue CJ-P (2011) The posterolateral corner: surgical approach and technique overview. Orthop J Sports Med 5:2325967117730805, Hewison CE, Tran MN, Kaniki N, Remtulla A, Bryant D, Getgood AM (2015) Lateral extra-articular Tenodesis reduces rotational laxity when combined with anterior cruciate ligament reconstruction: a systematic review of the literature. Torzilli PA , Greenberg RL, Insall J. JBJS 63:954–960, Article  Other techniques to quantify the pivot shift test measure the acceleration of the tibia on the femur during the pivot shift test with accelerometers or gyroscope sensors [8, 43, 53, 55, 59]. The authors prefer to perform a modification of the Lemaire technique whenever the patient has high grade rotatory instability, persistent intraoperative rotational instability after anatomic ACL-R, and when addressing of concomitant pathology. The authors declare that they have no competing interests. The graft is tensioned with the knee in external rotation and flexed to 30 degrees. Please read and accept the terms and conditions and check the box to generate a sharing link. Knee Surg Sports Traumatol Arthrosc 15:1009–1012, Musahl V, Citak M, O’Loughlin PF, Choi D, Bedi A, Pearle AD (2010) The effect of medial versus lateral Meniscectomy on the stability of the anterior cruciate ligament-deficient knee. Meniscus tears, especially root tears, can cause increased rotatory knee laxity in an ACL-deficient knee [35, 85, 89]. Increased posterior tibial translation at 30 degrees of knee flexion is indicative of an isolated posterolateral corner (PLC) injury, while increased laxity at 30 and 90 degrees of knee flexion is indicative of concomitant PLC and PCL injury [13]. the site you are agreeing to our use of cookies. The patient tests first the good leg and then the injured leg. The authors concluded that ACL-R with LET in a select group of young patients significantly reduces graft failure and persistent anterolateral rotatory knee laxity at 2 years post operatively [27]. An in vitro biomechanical evaluation of anterior-posterior motion of the knee Tibial displacement, rotation, and torque J Bone Joint Surg 64A: Galway RD, Beaupré A., Maclntosh DL Pivot shift A clinical sign of symptomatic anterior cruciate insufficiency (abstract). J Bone Joint Surg 99:305–314, Park HS, Wilson NA, Zhang LQ (2008) Gender differences in passive knee biomechanical properties in tibial rotation. Lean Library can solve it. Knee Surg Sports Traumatol Arthrosc 20:5–47, Schon JM, Moatshe G, Brady AW, Cruz RS, Chahla J, Dornan GJ et al (2016) Anatomic anterolateral ligament reconstruction of the knee leads to overconstraint at any fixation angle. Fetto JF, Marshall JL Injury to the anterior cruciate ligament producing the pivot-shift sign An experimental study on cadaver specimens J Bone Joint Surg 61A. A quantitative evaluation of the pivot shift test can be achieved with the assistance of different navigation systems using dynamic radio-stereometry, stereo-dynamic fluoroscopy, opto-electronic measurement, or electromagnetic measurement [7, 12, 14, 16, 20, 34, 39, 44, 45, 54, 74]. The intra-articular graft is then passed through the femoral notch, over the top of the femoral condyle, deep to the LCL, and finally attached to Gerdy’s tubercle. A 1 cm strip of ITB is harvested and detached proximally. Various clinical and radiographic tools are available for the treating surgeon to diagnose this condition. An understanding of the pathoanatomy of anterolateral rotatory instability (ALRI) has been complicated by the wide variety of nomenclature used in the literature. J Orthop Sports Phys Ther 36:267–288, Berruto M, Uboldi F, Gala L, Marelli B, Albisetti W (2013) Is triaxial accelerometer reliable in the evaluation and grading of knee pivot-shift phenomenon?,, The pivot shift test is the only dynamic and most specific clinical test for ACL injury, as well as the most representative of knee dysfunction and predictive of patient outcome [5, 16, 32, 49]. A reverse pivot shift test consists of applying a valgus load with the tibia in external rotation while bringing the knee from flexion to extension. The pivot shift test is divided into two phases, an anterior subluxation of the lateral tibia plateau and its spontaneous reduction [25, 32]. As techniques have evolved and our knowledge of the knee improved, a trend to include an LET has emerged. This study specifically assessed high risk patients, including those that had two of the three following criteria: generalized laxity, returning to high risk/pivoting sports, and grade 2 pivot shift or greater. Lemaire M., Miremad C. Les instabilites chroniques anteneures et internes du genou etude theorique, diagnostic clinique et radiologique Rev Chir Orthop 69: Losee RE Concepts of the pivot shift Clin Orthop 172. Simply select your manager software from the list below and click on download. Am J Sports Med 18:262–266, Engebretsen L, Lind M (2015) Anteromedial rotatory laxity. The patient then flexes the knee to 20 degrees and rotates the femur on the tibia medially and laterally three times while maintaining the 20 degrees flexion. Springer Nature. Article  c, viewed from the anterolateral portal, demonstrates the tip aimer placed in the center of the tibia footprint. : The diagnostic accuracy of ruptures of anterior cruciate ligament comparing the Lachman test, the anterior drawer sign and the pivot shift test in acute and chronic knee injuries Am.J. The patient then flexes the knee to 20 degrees and rotates the femur on the tibia medially and laterally three times while maintaining the 20 degrees flexion. A positive dial test, consisting of increased external rotation at 30 and 90 degrees of knee flexion with anterior subluxation of the medial tibial plateau, is also indicative of a complete injury to the medial structures causing AMRI [19]. Am J Sports Med 29:272–279, PubMed  We concluded that more diagnostic information on the magnitude of the anterior knee subluxation in the anterior cruciate deficient knee is available by perform ing the pivot shift test starting with the tibia in external rotation and using a technique that enhances anterior tibial translation and avoids excessive internal tibial rotation. Various studies have shown the addition of LET to an anatomic ACL-R decreased rotational knee laxity with no increased risk of osteoarthritis [22, 31, 60, 76, 89]. Knee Surg Sports Traumatol Arthrosc 27:646–651, Hughston JCA, James R, Cross MJ, Moschi A (1976) Classification of knee ligament instabilities part 1. Arthroscopy 32(10):2039–2047, Flandry F, Sinco SM (2006) Surgical treatment of chronic posterolateral rotatory instability of the knee using capsular procedures. The graft is passed deep to the LCL (black arrow) and attached superolaterally to the distal femur at Lemaire’s point with a staple (forceps). Early work showed that anterior cruciate ligament (ACL) incompetence is necessary for pathologic internal rotation of the tibia on the femur, as division of the anterolateral structures of the knee with an intact ACL did not produce significant tibial internal rotation on the femur [52]. J Orthop Res 28:164–169, Lopomo N, Zaffagnini S, Signorelli C, Bignozzi S, Giordano G, Marcheggiani Muccioli GM et al (2012) An original clinical methodology for non-invasive assessment of pivot-shift test. Bony morphology on the tibia and femur have been associated with an increased risk of ACL injury and rotatory knee laxity. Clin Orthop Relat Res 147:45–50, Getgood A, Brown C, Lording T, Amis A, Claes S, Geeslin A et al (2019) The anterolateral complex of the knee: results from the international ALC consensus group meeting. 3). In a biomechanical study of ACL-deficient and intact knees, the authors suggested that the ITB played the role of primary restraint to internal tibial rotation, particularly with greater knee flexion; however, a separate study reported that a positive pivot shift test still occurred in ACL-deficient knees with an intact ITB and a portion of the anterolateral complex known as the ALL, suggesting that these anterolateral structures are secondary stabilizers to the ACL in controlling internal tibial rotation [42, 71]. Coupled rotation refers to the obligatory internal tibial rotation that occurs during anterior tibial translation when an anterior tibial load is applied [16, 81]. J Bone Joint Surg Br 69:294–299, Kennedy J, Stewart R, Walker DM (1978) Anterolateral rotatory instability of the knee joint. Knee Surg Sports Traumatol Arthrosc 20:718–723, Labbe DR, de Guise JA, Mezghani N, Godbout V, Grimard G, Baillargeon D et al (2011) Objective grading of the pivot shift phenomenon using a support vector machine approach. Am J Sports Med 39:1332–1340, Uhorchak JM, Scoville CR, Williams GN, Arciero RA, St Pierre P, Taylor DC (2003) Risk factors associated with noncontact injury of the anterior cruciate ligament: a prospective four-year evaluation of 859 west point cadets. Create a link to share a read only version of this article with your colleagues and friends. Please check you selected the correct society from the list and entered the user name and password you use to log in to your society website. J Bone J Surg Am 60:1015–1030, MacIntosh D (1976) Lateral substitution reconstruction. Knee Surg Sports Traumatol Arthrosc 27:166–176, Getgood AM, Bryant D, Litchfield RB, McCormack RG, Heard M, MacDonald PB et al (2019) Lateral Extra-Articular Tenodesis Reduces Failure of Hamstring Tendon Autograft ACL Reconstruction-Two Year Outcomes from the STABILITY Study Randomized Clinical Trial. Am J Sports Med 35:1098–1104, Hoshino Y, Miyaji N, Nishida K, Nishizawa Y, Araki D, Kanzaki N et al (2019) The concomitant lateral meniscus injury increased the pivot shift in the anterior cruciate ligament-injured knee. J Bone Joint Surg Am 60:1031–1039, Kittl C, El-Daou H, Athwal KK, Gupte CM, Weiler A, Williams A et al (2016) The role of the anterolateral structures and the ACL in controlling laxity of the intact and ACL-deficient knee. A diagnostic test and operative repair. Google Scholar, Nielsen S, Ovesen J, Rasmussen O (1984) The anterior cruciate ligament of the knee: an experimental study of its importance in rotatory knee instability. By using the Porto-Knee Testing Device (PKTD®, Soplast, Valongo, Portugal) that applies a specified anterior load and internal rotation torque to the knee, the dynamic MRI can observe rotatory knee instability with a differential cut-off value of 3.5 mm between the medial and lateral tibial plateau [16, 21]. I have read and accept the terms and conditions, View permissions information for this article. Before and after ligament sectioning we determined the limits of knee motion under defined loading conditions. If you have an individual subscription to this content, or if you have purchased this content through Pay Per Article within the past 24 hours, you can gain access by logging in with your username and password here: This site uses cookies. The external-rotation recurvatum test is performed by grasping bilateral great toes and lifting the leg off of the examination surface, with positive findings including knee recurvatum, tibial external rotation, and increased varus deformity [13]. Hughes, J.D., Rauer, T., Gibbs, C.M. An in vivo biomechanical evaluation of the anterior-posterior motion of the knee Roentgeographic measurement technique, stress machine, and stable population J Bone Joint Surg 63A. Besides the above mentioned imaging modalities, several systems of static measurement of rotational knee instability have been described in the last two decades [9, 56, 62, 64, 72, 84]. Non-invasive computer navigation can quantify the pivot shift maneuver... Augmentation of Anatomic Anterior Cruciate Ligament Reconstruction Wit... Validity of the Genourob arthrometer in the evaluation of total thickn... Allum R., Jones D., Mowbray Mas, et al. Arthroscopy 25:488–495, Jakob RP, Staubli HU, Deland JT (1987) Grading the pivot shift. To understand the abnormal joint kinematics in rotatory knee instability, a review of the anatomical structures and their graded role in maintaining rotational stability, the importance of concomitant pathologies, as well as the different components of the knee rotation motion will be presented. Numerous techniques have been described, performed in conjunction with ACLR, a few of which are briefly detailed below in the surgical technique section. Correspondence to Similarly, the in situ force in the ACL during simulated pivot shift testing was significantly greater than the forces in the anterolateral corner (ALC) at low flexion angles, but significantly lower at higher degrees of knee flexion, inferring that joint position is an important factor in determining the primary component responsible for rotational integrity [4]. AMRI is clinically evaluated with physical examination findings of pain in the medial and posteromedial aspects of the knee as well as increased laxity with abduction stress applied at 30 degrees of knee flexion, coupled with anterior rotatory subluxation of the medial tibial plateau relative to the corresponding femoral condyle [86]. the menisci). The white arrow points to a peripheral tear in the posterior horn of the medial meniscus, aka a ramp lesion. Grood ES, Noyes FR Diagnosis and classification of knee ligament injuries Part I Biomechanical precepts, in Feagin J Jr (ed) The Crucial Ligaments New York, Churchill Livingstone. Am J Sports Med 38:1094–1102, Pfeiffer TR, Burnham JM, Kanakamedala AC, Hughes JD, Zlotnicki J, Popchak A et al (2019) Distal femur morphology affects rotatory knee instability in patients with anterior cruciate ligament ruptures. Am J Sports Med 31:831–842, Warren RF, Marshall JL (1978) Injuries of the anterior cruciate and medial collateral ligaments of the knee: a long-term follow-up of 86 cases-part II. Influence of Anterior Cruciate Ligament Bundles on Knee Kinematics: Clinical Assessment Using C... Reconstruction of the Posterolateral Corner After Sequential Sectioning Restores Knee Kinematics. The analysis of the data showed that examiners typically induced a coupled anterior translation and internal tibial rotation to produce an anterior tibial subluxation, and a coupled posterior translation and external tibial rotation to induce the reduction event. Oper Tech Sports Med 9:84–90, Leitze Z, Losee RE, Jokl P, Johnson TR, Feagin JA (2005) Implications of the pivot shift in the ACL-deficient knee. Am J Sports Med 43:1598–1605, Strum GM, Fox JM, Ferkel RD, Dorey FH, Del Pizzo W, Friedman MJ et al (1989) Intraarticular versus intraarticular and extraarticular reconstruction for chronic anterior cruciate ligament instability. Access to society journal content varies across our titles. Clin Orthop Relat Res 136:198–211, Williams A, Ball S, Stephen J, White N, Jones M, Amis A (2017) The scientific rationale for lateral tenodesis augmentation of intra-articular ACL reconstruction using a modified ‘Lemaire’ procedure. Recently, however, as ACL-R failures continue to occur and surgical technique improves, renewed interest in LET procedures has arisen in order to improve rotatory control of the knee [18]. 4). a demonstrates 3-4 mm of posterior wall remaining after reaming the femoral tunnel, viewed from the anteromedial portal. Find out about Lean Library here, If you have access to journal via a society or associations, read the instructions below. Arthroscopy 35:684–690, Musahl V, Bell KM, Tsai AG, Costic RS, Allaire R, Zantop T et al (2007) Development of a simple device for measurement of rotational knee laxity., DOI: By continuing to browse This technique, described in 1998, combines ACL-R with an LET, for a combined intra-articular and extra-articular reconstruction. Am J Sports Med 44:585–592, Robinson J, Carrat L, Granchi C, Colombet P (2007) Influence of anterior cruciate ligament bundles on knee kinematics: clinical assessment using computer-assisted navigation. Another useful clinical test includes the rotatory instability test, which is an anterior drawer test with the knee in 15 degrees of external rotation., Rahnemai-Azar AA, Yaseen Z, van Eck CF, Irrgang JJ, Fu FH, Musahl V (2016) Increased lateral Tibial plateau slope predisposes male college football players to anterior cruciate ligament injury. This includes placing the graft in the center of the anatomic footprints of the ACL on the tibia and femur. 2) and ramp lesions, have been implicated in rotatory knee instability [67, 75, 85, 89]. J EXP ORTOP 6, 48 (2019).

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