Similarities and Differences of Diagnostic Manual Tests for Anterior Cruciate Ligament Insufficiency

Background: The Lachman and pivot-shift tests are 2 standard manual tests to diagnose anterior cruciate ligament (ACL) insufficiency. However, the global variation of these testing procedures is not known. Purpose: To survey currently used testing techniques and to measure the knee movement during manual tests among various expert surgeons from across the globe. Study Design: Controlled laboratory study. Methods: Part 1: descriptive survey. A questionnaire asking about testing procedures of Lachman and pivot-shift tests was conducted among 33 ACL surgeons. Part 2: knee kinematics comparison. Lachman and pivot-shift tests were performed on a unilateral ACL-injured patient by 5 surgeons, while knee kinematics was recorded by an electromagnetic system. Tibial translation was measured during the Lachman test, while tibial translation, rotation, and pivot-shift acceleration were calculated during the pivot-shift test. Results: Part 1: Tibial anterior drawer by a medially placed hand was widely advocated for the Lachman test. Flexion type of the pivot-shift test maneuver was supported by two thirds, while extension type was supported by one third. However, the “feeling” of subluxation or reduction during the pivot shift was the primary evaluation method used by the vast majority of surgeons. Part 2: Increased tibial translation during the Lachman test was observed in the ACL-injured knee with significant variation between examiners (P < .01). Tibial translation and pivot-shift acceleration during the pivot-shift test increased in the ACL-injured side (P < .01), but tibial rotation was too diverse to find any trend (P = .31). Tibial translation and acceleration of the pivot shift in the ACL-injured knee showed no significant difference between examiners (P > .05). Conclusion: The Lachman test can display a wide variation of actual movement despite maneuver similarity, while the pivot-shift test could possibly be measurable by tibial translation and/or acceleration beyond their procedural variation. Clinical Relevance: We should recognize the limitations of these manual tests and the possibilities of their objective measurement.

[1]  R P Jakob,et al.  Grading the pivot shift. Objective tests with implications for treatment. , 1987, The Journal of bone and joint surgery. British volume.

[2]  M. Kurosaka,et al.  Double-bundle ACL Reconstruction Can Improve Rotational Stability , 2007, Clinical Orthopaedics and Related Research.

[3]  E S Grood,et al.  An analysis of the pivot shift phenomenon , 1991, The American journal of sports medicine.

[4]  W. Southwick,et al.  Anterior subluxation of the lateral tibial plateau. A diagnostic test and operative repair. , 1978, The Journal of bone and joint surgery. American volume.

[5]  T. Wickiewicz,et al.  The pivot shift phenomenon: Results and description of a modified clinical test for anterior cruciate ligament insufficiency , 1988, The American journal of sports medicine.

[6]  Kouki Nagamune,et al.  Intraoperative Measurement of Pivot Shift by Electromagnetic Sensors , 2008 .

[7]  Kouki Nagamune,et al.  In Vivo Measurement of the Pivot-Shift Test in the Anterior Cruciate Ligament—Deficient Knee Using an Electromagnetic Device , 2007, The American journal of sports medicine.

[8]  Daniel Kendoff,et al.  The pivot-shift phenomenon during computer-assisted anterior cruciate ligament reconstruction. , 2009, The Journal of bone and joint surgery. American volume.

[9]  Roland P. Jakob,et al.  A New Mechanical Testing Device for Measuring Anteroposterior Knee Laxity , 2004, The American journal of sports medicine.

[10]  久保 晴司.  Reliability and usefulness of a new in vivo measurement system of the pivot shift , 2007 .

[11]  V. Musahl,et al.  Lateral compartment translation predicts the grade of pivot shift: a cadaveric and clinical analysis , 2010, Knee Surgery, Sports Traumatology, Arthroscopy.

[12]  M Tew,et al.  Is the KT1000 knee ligament arthrometer reliable? , 1989, The Journal of bone and joint surgery. British volume.

[13]  T. Fukubayashi,et al.  Insufficiency of the anterior cruciate ligament. Review of our 118 cases. , 1979, Archives of orthopaedic and traumatic surgery. Archiv fur orthopadische und Unfall-Chirurgie.

[14]  Freddie H. Fu,et al.  A functional assessment of anterior cruciate ligament deficiency in an acute and clinical setting. , 1990, Journal of Orthopaedic and Sports Physical Therapy.

[15]  T. Matsushita,et al.  A prospective randomised study of anatomical single-bundle versus double-bundle anterior cruciate ligament reconstruction: quantitative evaluation using an electromagnetic measurement system , 2011, International Orthopaedics.

[16]  T. Matsushita,et al.  The use of an electromagnetic measurement system for anterior tibial displacement during the Lachman test. , 2011, Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association.

[17]  K. M. Singer,et al.  Clinical test for anterolateral rotary instability of the knee. , 1976, Clinical orthopaedics and related research.

[18]  Neila Mezghani,et al.  Feature selection using a principal component analysis of the kinematics of the pivot shift phenomenon. , 2010, Journal of biomechanics.

[19]  P. MacDonald,et al.  Accuracy and Reliability of Anterior Cruciate Ligament Clinical Examination in a Multidisciplinary Sports Medicine Setting , 2010, Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine.

[20]  Thore Zantop,et al.  Rotational instability of the knee: internal tibial rotation under a simulated pivot shift test , 2009, Archives of Orthopaedic and Trauma Surgery.

[21]  Daniel Kendoff,et al.  In vivo analysis of the pivot shift phenomenon during computer navigated ACL reconstruction , 2008, Knee Surgery, Sports Traumatology, Arthroscopy.

[22]  A A Amis,et al.  Intraoperative measurement of knee kinematics in reconstruction of the anterior cruciate ligament. , 2002, The Journal of bone and joint surgery. British volume.

[23]  J. Karlsson,et al.  Evaluation of the reproducibility of the KT‐1000 arthrometer , 2001, Scandinavian journal of medicine & science in sports.

[24]  J. Andrews,et al.  Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. , 1976, The Journal of bone and joint surgery. American volume.

[25]  Patrick Smolinski,et al.  Evaluation of rotational instability in the anterior cruciate ligament deficient knee using triaxial accelerometer: a biomechanical model in porcine knees , 2011, Knee Surgery, Sports Traumatology, Arthroscopy.

[26]  R. Johnson,et al.  Clinical versus instrumented knee testing on autopsy specimens. , 1992, Clinical orthopaedics and related research.

[27]  H. Hiraoka,et al.  Gravity-assisted pivot-shift test for anterior cruciate ligament injury: a new procedure to detect anterolateral rotatory instability of the knee joint , 2005, Knee Surgery, Sports Traumatology, Arthroscopy.

[28]  Andrew A. Amis,et al.  The pivot-shift phenomenon: a clinical and biomechanical perspective , 1998 .

[29]  J. Torg,et al.  Clinical I diagnosis of anterior cruciate ligament instability in the athlete , 1976, The American journal of sports medicine.

[30]  G. Losse,et al.  Instrumented measurement of anterior laxity of the knee. , 1985, The Journal of bone and joint surgery. American volume.

[31]  E S Grood,et al.  A joint coordinate system for the clinical description of three-dimensional motions: application to the knee. , 1983, Journal of biomechanical engineering.

[32]  Galway Hr,et al.  The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency. , 1980 .

[33]  E S Grood,et al.  Arthroscopy in acute traumatic hemarthrosis of the knee. Incidence of anterior cruciate tears and other injuries. , 1980, The Journal of bone and joint surgery. American volume.