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Knee Surgery, Sports Traumatology, Arthroscopy
Published in: Knee Surgery, Sports Traumatology, Arthroscopy 10/2017

01-10-2017 | Knee

Analysis of the influence of anaesthesia on the clinical and quantitative assessment of the pivot shift: a multicenter international study

Authors: Nicola Lopomo, Cecilia Signorelli, Amir Ata Rahnemai-Azar, Federico Raggi, Yuichi Hoshino, Kristian Samuelsson, Volker Musahl, Jon Karlsson, Ryosuke Kuroda, Stefano Zaffagnini, PIVOT Study Group

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 10/2017

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Abstract

Purpose

The main goal of this work was to evaluate the pivot shift test in awake and anesthetized patients by using two different quantitative methodologies and comparing the results with the standard clinical grading, taking advantage of a multicenter international study.

Methods

Patients between 16 and 50 years of age undergoing primary unilateral single-bundle anterior cruciate ligament (ACL) reconstruction were considered eligible. The pivot shift test was performed pre-operatively, with the patient awake and again with the patient under general anaesthesia. The pivot shift test was clinically graded as defined by the International Knee Documentation Committee. The instrumented assessment was performed by using two non-invasive acquisition systems; specifically, a system exploiting an inertial sensor and a video-based application developed on a commercial tablet using skin markers. Lateral compartment translation and the tibial acceleration reached during joint reduction were used as quantitative parameters.

Results

A total of 103 patients were enrolled in the study. Statistically significant difference was found between the distributions of clinical grade evaluated in awake patients and those under general anaesthesia (P < 0.01). Comparing awake patients to those under general anaesthesia, lower values were found both for tibial acceleration (3.7 ± 1.5 vs 6.0 ± 4.6 m/s2, P < 0.01) and lateral compartment translation of the involved limb (2.2 ± 1.7 vs 3.0 ± 2.2 mm, P < 0.01).

Conclusions

This study indicated that significant differences in the grading of the pivot shift test exist between awake and anesthetized patients, regardless of the use of quantitative instruments during the evaluation. Actual clinical assessment reported indeed its weakness, presenting subjective variability and dependence on tester’s experience. However, several factors might influence the validity of awake examination such as experience level of examiner and cultural factors, as seen in this international multicenter study.

Level of evidence

Prospective comparative study, Level II.
Literature
1.
Ahldén M, Samuelsson K, Fu FH, Musahl V, Karlsson J (2013) Rotatory Knee Laxity. Clin Sports Med 32:37–46CrossRefPubMed
2.
Anderson AF, Irrgang JJ, Kocher MS, Mann BJ, Harrast JJ, International Knee Documentation Committee (2006) The International Knee Documentation Committee Subjective Knee Evaluation Form: normative data. Am J Sports Med 34:128–135CrossRefPubMed
3.
Araujo PH, Ahlden M, Hoshino Y, Muller B, Moloney G, Fu FH, Musahl V (2012) Comparison of three non-invasive quantitative measurement systems for the pivot shift test. Knee Surgery Sport Traumatol Arthrosc 20:692–697CrossRef
4.
Bach BR, Warren RF, Wickiewicz TL (1988) The pivot shift phenomenon: results and description of a modified clinical test for anterior cruciate ligament insufficiency. Am J Sports Med 16:571–576CrossRefPubMed
5.
Benjaminse A, Gokeler A, van der Schans CP (2006) Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther 36:267–288CrossRefPubMed
6.
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? Knee Surgery Sport Traumatol Arthrosc 21:981–985CrossRef
7.
Donaldson WF, Warren RF, Wickiewicz T (1985) A comparison of acute anterior cruciate ligament examinations: initial versus examination under anesthesia. Am J Sports Med 13:5–10CrossRefPubMed
8.
van Eck CF, van den Bekerom MPJ, Fu FH, Poolman RW, Kerkhoffs GMMJ (2013) Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of physical examinations with and without anaesthesia. Knee Surgery Sport Traumatol Arthrosc 21:1895–1903CrossRef
9.
Galway HR, MacIntosh DL (1980) The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency. Clin Orthop Relat Res 147:45–50
10.
Hefti E, Müller W, Jakob RP, Stäubli HU (1993) Evaluation of knee ligament injuries with the IKDC form. Knee Surgery Sport Traumatol Arthrosc 1:226–234CrossRef
11.
Hoshino Y, Araujo P, Ahlden M, Moore CG, Kuroda R, Zaffagnini S, Karlsson J, Fu FH, Musahl V (2012) Standardized pivot shift test improves measurement accuracy. Knee Surgery Sport Traumatol Arthrosc 20:732–736CrossRef
12.
Hoshino Y, Araujo P, Ahldén M, Samuelsson K, Muller B, Hofbauer M, Wolf MR, Irrgang JJ, Fu FH, Musahl V (2013) Quantitative evaluation of the pivot shift by image analysis using the iPad. Knee Surg Sports Traumatol Arthrosc 21:975–980CrossRefPubMed
13.
Hoshino Y, Araujo P, Irrgang JJ, Fu FH, Musahl V (2012) An image analysis method to quantify the lateral pivot shift test. Knee Surgery Sport Traumatol Arthrosc 20:703–707CrossRef
14.
Jakob RP, Stäubli HU, Deland JT (1987) Grading the pivot shift. Objective tests with implications for treatment. J Bone Joint Surg Br 69:294–299PubMed
15.
Jensen K (1990) Manual laxity tests for anterior cruciate ligament injuries. J Orthop Sports Phys Ther 11:474–481CrossRefPubMed
16.
Kaplan N, Wickiewicz TL, Warren RF (1990) Primary surgical treatment of anterior cruciate ligament ruptures. A long-term follow-up study. Am J Sports Med 18:354–358CrossRefPubMed
17.
Katz JW, Fingeroth RJ (1986) The diagnostic accuracy of ruptures of the anterior cruciate ligament comparing the Lachman test, the anterior drawer sign, and the pivot shift test in acute and chronic knee injuries. Am J Sports Med 14:88–91CrossRefPubMed
18.
Kievit AJ, Jonkers FJ, Barentsz JH, Blankevoort L (2013) A cross-sectional study comparing the rates of osteoarthritis, laxity, and quality of life in primary and revision anterior cruciate ligament reconstructions. Arthroscopy 29:898–905CrossRefPubMed
19.
Kim SJ, Kim HK (1995) Reliability of the anterior drawer test, the pivot shift test, and the Lachman test. Clin Orthop Relat Res 317:237–242
20.
Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ (2004) Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med 32:629–634CrossRefPubMed
21.
Kuroda R, Hoshino Y, Kubo S, Araki D, Oka S, Nagamune K, Kurosaka M (2012) Similarities and differences of diagnostic manual tests for anterior cruciate ligament insufficiency: a global survey and kinematics assessment. Am J Sports Med 40:91–99CrossRefPubMed
22.
Labbe DR, de Guise JA, Mezghani N, Godbout V, Grimard G, Baillargeon D, Lavigne P, Fernandes J, Ranger P, Hagemeister N (2010) Feature selection using a principal component analysis of the kinematics of the pivot shift phenomenon. J Biomech 43:3080–3084CrossRefPubMed
23.
24.
Lane CG, Warren RF, Stanford FC, Kendoff D, Pearle AD (2008) In vivo analysis of the pivot shift phenomenon during computer navigated ACL reconstruction. Knee Surgery Sport Traumatol Arthrosc 16:487–492CrossRef
25.
Larson RL (1983) Physical examination in the diagnosis of rotatory instability. Clin Orthop Relat Res 172:38–44
26.
Leitze Z, Losee RE, Jokl P, Johnson TR, Feagin JA (2005) Implications of the pivot shift in the ACL-deficient knee. Clin Orthop Relat Res 436:229–236CrossRef
27.
Liu SH, Osti L, Henry M, Bocchi L (1995) The diagnosis of acute complete tears of the anterior cruciate ligament. Comparison of MRI, arthrometry and clinical examination. J Bone Joint Surg Br 77:586–588PubMed
28.
Lopomo N, Signorelli C, Bonanzinga T, Muccioli GMM, Visani A, Zaffagnini S (2012) Quantitative assessment of pivot-shift using inertial sensors. Knee Surgery Sport Traumatol Arthrosc 20:713–717CrossRef
29.
Lopomo N, Zaffagnini S, Amis AA (2013) Quantifying the pivot shift test: a systematic review. Knee Surgery Sport Traumatol Arthrosc 21:767–783CrossRef
30.
Lopomo N, Zaffagnini S, Bignozzi S, Visani A, Marcacci M (2010) Pivot-shift test: analysis and quantification of knee laxity parameters using a navigation system. J Orthop Res 28:164–169PubMed
31.
Lopomo N, Zaffagnini S, Signorelli C, Bignozzi S, Giordano G, Marcheggiani Muccioli GM, Visani A (2011) An original clinical methodology for non-invasive assessment of pivot-shift test. Comput Methods Biomech Biomed Engin 15(12):1323–1328CrossRefPubMed
32.
Losee RE (1983) Concepts of the pivot shift. Clin Orthop Relat Res 172:45–51
33.
Lucie RS, Wiedel JD, Messner DG (1984) The acute pivot shift: clinical correlation. Am J Sports Med 12:189–191CrossRefPubMed
34.
Maeyama A, Hoshino Y, Debandi A, Kato Y, Saeki K, Asai S, Goto B, Smolinski P, Fu FH (2011) Evaluation of rotational instability in the anterior cruciate ligament deficient knee using triaxial accelerometer: a biomechanical model in porcine knees. Knee Surgery Sport Traumatol Arthrosc. 19:1233–1238CrossRef
35.
Makhmalbaf H, Moradi A, Ganji S, Omidi-Kashani F (2013) Accuracy of Lachman and anterior drawer tests for anterior cruciate ligament injuries. Arch Bone Jt Surg 1:94–97PubMedPubMedCentral
36.
Matsushita T, Kuroda R, Nishizawa Y, Araki D, Hoshino Y, Nagai K, Matsumoto T, Kurosaka M (2015) Clinical outcomes and biomechanical analysis of posterolateral bundle augmentation in patients with partial anterior cruciate ligament tears. Knee Surgery Sport Traumatol Arthrosc. doi:10.​1007/​s00167-015-3691-8
37.
Matsushita T, Oka S, Nagamune K, Matsumoto T, Nishizawa Y, Hoshino Y, Kubo S, Kurosaka M, Kuroda R (2013) Differences in Knee kinematics between awake and anesthetized patients during the Lachman and Pivot-shift tests for anterior cruciate ligament deficiency. Orthop J Sport Med 1:1–6
38.
Moses B, Orchard J, Orchard J (2012) Systematic review: annual incidence of ACL injury and surgery in various populations. Res Sports Med 20:157–179PubMed
39.
Muller B, Hofbauer M, Rahnemai-Azar AA, Wolf M, Araki D, Hoshino Y, Araujo P, Debski RE, Irrgang JJ, Fu FH, Musahl V (2016) Development of computer tablet software for clinical quantification of lateral knee compartment translation during the pivot shift test. Comput Methods Biomech Biomed Eng 19:217–228CrossRef
40.
Musahl V, Hoshino Y, Ahlden M, Araujo P, Irrgang JJ, Zaffagnini S, Karlsson J, Fu FH (2012) The pivot shift: a global user guide. Knee Surgery Sport Traumatol Arthrosc 20:724–731CrossRef
41.
Musahl V, Kopf S, Rabuck S, Becker R, van der Merwe W, Zaffagnini S, Fu FH, Karlsson J (2012) Rotatory knee laxity tests and the pivot shift as tools for ACL treatment algorithm. Knee Surgery Sport Traumatol Arthrosc 20:793–800CrossRef
42.
Nakamura K, Koga H, Sekiya I, Watanabe T, Mochizuki T, Horie M, Nakamura T, Otabe K, Muneta T (2015) Evaluation of pivot shift phenomenon while awake and under anaesthesia by different manoeuvres using triaxial accelerometer. Knee Surg Sports Traumatol Arthrosc. doi:10.​1007/​s00167-015-3740-3
43.
Noyes FR, Grood ES, Cummings JF, Wroble RR (1991) An analysis of the pivot shift phenomenon. The knee motions and subluxations induced by different examiners. Am J Sports Med 19:148–155CrossRefPubMed
44.
Noyes FR, Matthews DS, Mooar PA, Grood ES (1983) The symptomatic anterior cruciate-deficient knee. Part II: the results of rehabilitation, activity modification, and counseling on functional disability. J Bone Joint Surg Am 65:163–174CrossRefPubMed
45.
Noyes FR, Mooar PA, Matthews DS, Butler DL (1983) The symptomatic anterior cruciate-deficient knee. Part I: the long-term functional disability in athletically active individuals. J Bone Joint Surg Am 65:154–162CrossRefPubMed
46.
Ohashi B, Lopomo N, Zaffagnini S, Hoshino Y, Kuroda R, Irrgang JJ, Musahl V, Pivot Study Group (2014) Quantitative measurement of a standardized Pivot-shift : comparison between the awake and the examination under anesthesia in patients with acute ACL Injury. ORS 2014 Annual Meeting, pp 6–8
47.
48.
Prins M (2006) The Lachman test is the most sensitive and the pivot shift the most specific test for the diagnosis of ACL rupture. Aust J Physiother 52:66CrossRefPubMed
49.
Prodromos CC, Han Y, Rogowski J, Joyce B, Shi K (2007) A meta-analysis of the incidence of anterior cruciate ligament tears as a function of gender, sport, and a knee injury-reduction regimen. Arthroscopy 23(1320–1325):e6
50.
Sandberg R, Balkfors B, Henricson A, Westlin N (1986) Stability tests in knee ligament injuries. Arch Orthop Trauma Surg 106:5–7CrossRefPubMed
51.
Scholten RJPM, Opstelten W, van der Plas CG, Bijl D, Deville WLJM, Bouter LM (2003) Accuracy of physical diagnostic tests for assessing ruptures of the anterior cruciate ligament: a meta-analysis. J Fam Pract 52:689–694PubMed
52.
Swain MS, Henschke N, Kamper SJ, Downie AS, Koes BW, Maher CG (2014) Accuracy of clinical tests in the diagnosis of anterior cruciate ligament injury: a systematic review. Chiropr Man Therap 22:25CrossRefPubMedPubMedCentral
53.
Zaffagnini S, Lopomo N, Signorelli C, Marcheggiani Muccioli GM, Bonanzinga T, Grassi A, Visani A, Marcacci M (2013) Innovative technology for Knee laxity evaluation: clinical applicability and reliability of inertial sensors for quantitative analysis of the Pivot-Shift Test. Clin Sports Med 32:61–70CrossRefPubMed
Metadata
Title
Analysis of the influence of anaesthesia on the clinical and quantitative assessment of the pivot shift: a multicenter international study
Authors
Nicola Lopomo
Cecilia Signorelli
Amir Ata Rahnemai-Azar
Federico Raggi
Yuichi Hoshino
Kristian Samuelsson
Volker Musahl
Jon Karlsson
Ryosuke Kuroda
Stefano Zaffagnini
PIVOT Study Group
Publication date
01-10-2017
Publisher
Springer Berlin Heidelberg
Published in
Knee Surgery, Sports Traumatology, Arthroscopy / Issue 10/2017
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI
https://doi.org/10.1007/s00167-016-4130-1

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