The Pivot Shift Test Is of Limited Clinical Relevance in the Arthritic Anterior Cruciate Ligament–Deficient Knee

ABSTRACT

The pivot shift test is used to assess the integrity of the anterior cruciate ligament (ACL).This test has been shown to be highly sensitive in detecting instability in knees with complete ACL rupture. However, in the presence of osteoarthritis, the rotation and subluxation required for the pivot shift to be effective can be limited and therefore is likely to impact upon the reliability of this test. We performed the pivot shift test on 50 patients, under general anesthesia, prior to total knee replacement and then recorded the integrity of the ACL intraoperatively. This allowed us to assess the accuracy of this test in the presence of significant osteoarthritis. Of the 50 knees tested, none had a positive pivot shift test preoperatively; however, 14% of the knees included in the study had a completely ruptured ACL. This gives a sensitivity of 0% and a specificity of 1% for the pivot shift test for ACL ruptures in the presence of established osteoarthritis. We conclude that the pivot shift test may not be a reliable test for ACL function in the presence of symptomatic arthritis of the knee.

KEYWORDS

Pivot shift - anterior cruciate ligament - knee - osteoarthritis - unicompartmental knee replacement - total knee replacement - anterolateral instability - rotatory instability

REFERENCES

• 1 Galway H R, MacIntosh D L. The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency.  Clin Orthop Relat Res. 1980;  147 45-50
• 2 Decker R, Ruf W. [The diagnostic certainty of various methods of evaluating recent trauma to knee ligaments].  Unfallchirurgie. 1988;  14 204-210
• 3 Allum R, Jones D, Mowbray M A, Galway H R. Triaxial electrogoniometric examination of the pivot shift sign for rotatory instability of the knee.  Clin Orthop Relat Res. 1984;  183 144-146
• 4 Kujala U M, Nelimarkka O, Koskinen S K. Relationship between the pivot shift and the configuration of the lateral tibial plateau.  Arch Orthop Trauma Surg. 1992;  111 228-229
• 5 Kim S J, Kim H K. Reliability of the anterior drawer test, the pivot shift test, and the Lachman test.  Clin Orthop Relat Res. 1995;  317 237-242
• 6 Donaldson III W F, Warren R F, Wickiewicz T. A comparison of acute anterior cruciate ligament examinations. Initial versus examination under anesthesia.  Am J Sports Med. 1985;  13 5-10
• 7 Lucie R S, Wiedel J D, Messner D G. The acute pivot shift: clinical correlation.  Am J Sports Med. 1984;  12 189-191
• 8 Sandberg R, Balkfors B, Henricson A, Westlin N. Stability tests in knee ligament injuries.  Arch Orthop Trauma Surg. 1986;  106 5-7
• 9 Bull A M, Andersen H N, Basso O, Targett J, Amis A A. Incidence and mechanism of the pivot shift. An in vitro study.  Clin Orthop Relat Res. 1999;  363 219-231
• 10 Losee R E. Concepts of the pivot shift.  Clin Orthop Relat Res. 1983;  172 45-51
• 11 Slocum D B, James S L, Larson R L, Singer K M. Clinical test for anterolateral rotary instability of the knee.  Clin Orthop Relat Res. 1976;  118 63-69
• 12 Kanamori A, Zeminski J, Rudy T W, Li G, Fu F H, Woo S L. The effect of axial tibial torque on the function of the anterior cruciate ligament: a biomechanical study of a simulated pivot shift test.  Arthroscopy. 2002;  18 394-398
• 13 Hassler H, Jakob R P. [On the cause of the anterolateral instability of the knee joint. A study on 20 cadaver knee joints with special regard to the tractus iliotibialis (author's transl)].  Arch Orthop Trauma Surg. 1981;  98 45-50
• 14 Fetto J F, Marshall J L. Injury to the anterior cruciate ligament producing the pivot-shift sign.  J Bone Joint Surg Am. 1979;  61 710-714
• 15 Noyes F R, Grood E S, Cummings J F, Wroble R R. An analysis of the pivot shift phenomenon. The knee motions and subluxations induced by different examiners.  Am J Sports Med. 1991;  19 148-155
• 16 Ostrowski J A. Accuracy of 3 diagnostic tests for anterior cruciate ligament tears.  J Athl Train. 2006;  41 120-121
• 17 Johnson D L, Warner J J. Diagnosis for anterior cruciate ligament surgery.  Clin Sports Med. 1993;  12 671-684
• 18 Fetto J F, Marshall J L. The natural history and diagnosis of anterior cruciate ligament insufficiency.  Clin Orthop Relat Res. 1980;  147 29-38
• 19 Moro-oka T A, Muenchinger M, Canciani J P, Banks S A. Comparing in vivo kinematics of anterior cruciate-retaining and posterior cruciate-retaining total knee arthroplasty.  Knee Surg Sports Traumatol Arthrosc. 2007;  15 93-99
• 20 Stiehl J B, Komistek R D, Cloutier J M, Dennis D A. The cruciate ligaments in total knee arthroplasty: a kinematic analysis of 2 total knee arthroplasties.  J Arthroplasty. 2000;  15 545-550
• 21 Riddle D L, Jiranek W A, McGlynn F J. Yearly incidence of unicompartmental knee arthroplasty in the United States.  J Arthroplasty. 2008;  23 408-412
• 22 Geller J A, Yoon R S, Macaulay W. Unicompartmental knee arthroplasty: a controversial history and a rationale for contemporary resurgence.  J Knee Surg. 2008;  21 7-14
• 23 Suggs J F, Li G, Park S E, Steffensmeier S, Rubash H E, Freiberg A A. Function of the anterior cruciate ligament after unicompartmental knee arthroplasty: an in vitro robotic study.  J Arthroplasty. 2004;  19 224-229
• 24 Suggs J F, Li G, Park S E, Sultan P G, Rubash H E, Freiberg A A. Knee biomechanics after UKA and its relation to the ACL—a robotic investigation.  J Orthop Res. 2006;  24 588-594
• 25 Hernigou P, Deschamps G. Posterior slope of the tibial implant and the outcome of unicompartmental knee arthroplasty.  J Bone Joint Surg Am. 2004;  86-A 506-511
• 26 Pandit H, Beard D J, Jenkins C et al.. Combined anterior cruciate reconstruction and Oxford unicompartmental knee arthroplasty.  J Bone Joint Surg Br. 2006;  88 887-892
• 27 Trompeter A J, Gill K, Appleton M AC, Palmer S H. Predicting anterior cruciate ligament integrity in patients with osteoarthritis.  Knee Surg Sports Traumatol Arthrosc. 2009;  17 595-599
• 28 Rose N E, Gold S M. A comparison of accuracy between clinical examination and magnetic resonance imaging in the diagnosis of meniscal and anterior cruciate ligament tears.  Arthroscopy. 1996;  12 398-405