Clinical analysis of the pivot shift tests: description of the pivot drawer test

A clinical analysis of the pivot shift was performed by evaluating 100 patients with unilateral anterior cruciate ligament (ACL) insufficiency in an office setting. Each patient was examined in a random order using the Macintosh, Losee, Hughston, Slocum, pivot drawer, and flexion rotation drawer versions of the pivot shift test. Pathologic anterior tibial displacement was estimated with the Lachman test and quantitatively measured using the KT-1000 knee ligament arthrometer. Pivot shift was graded as 0 (absent), grade I (slight), grade II (definite subluxation), and grade III (subluxation and momentary locking). The presence or absence of any degree of pivot shift was correlated with the arthroscopic finding of a torn ACL. Results indicated the "drawer type" tests were significantly more sensitive than other versions of the pivot shift because they can be performed without causing significant pain and muscle spasm, and the limb position maximizes pathologic coupled motion. A correlation between increasing displacement estimated with the Lachman test and measured displacement with the KT-1000 arthrometer revealed that as pathologic displacement increases so does the grade of the Slocum, pivot drawer, and flexion rotation drawer tests. We recommend using the pivot drawer or flexion rotation drawer as a standard method for assessing the pivot shift phenomenon.     

Rotational instability of the knee: internal tibial rotation under a simulated pivot shift test

Introduction  Recently, several publications investigated the rotational instability of the human knee joint under pivot shift examinations and reported the internal tibial rotation as measurement for instrumented knee laxity measurements. We hypothesize that ACL deficiency leads to increased internal tibial rotation under a simulated pivot shift test. Furthermore, it was hypothesized that anatomic single bundle ACL reconstruction significantly reduces the internal tibial rotation under a simulated pivot shift test when compared to the ACL-deficient knee. Methods  In seven human cadaveric knees, the kinematics of the intact knee, ACL-deficient knee, and anatomic single bundle ACL reconstructed knee were determined in response to a 134 N anterior tibial load and a combined rotatory load of 10 N m valgus and 4 N m internal tibial rotation using a robotic/UFS testing system. Statistical analyses were performed using a two-way ANOVA test. Results  Single bundle ACL reconstruction reduced the anterior tibial translation under a simulated KT-1000 test significantly compared to the ACL-deficient knee (P < 0.05). After reconstruction, there was a statistical significant difference to the intact knee at 30° of knee flexion. Under a simulated pivot shift test, anatomic single bundle ACL reconstruction could restore the intact knee kinematics. Internal tibial rotation under a simulated pivot shift showed no significant difference in the ACL-intact, ACL-deficient and ACL-reconstructed knee. Conclusion  In conclusion, ACL deficiency does not increase the internal tibial rotation under a simulated pivot shift test. For objective measurements of the rotational instability of the knee using instrumented knee laxity devices under pivot shift mechanisms, the anterior tibial translation should be rather evaluated than the internal tibial rotation. This study was supported in part by a grant of the German Speaking Association of Arthroscopy (AGA).     

Effect of the iliotibial band on knee biomechanics during a simulated pivot shift test.

The purpose of this study was to evaluate the effect of the iliotibial band (ITB) on the kinematics of anterior cruciate ligament (ACL) intact and deficient knees and also on the in situ force in the ACL during a simulated pivot shift test. A combination of 10 N-m valgus and 5 N-m internal tibial torques was applied to 10 human cadaveric knees at 15 degrees, 30 degrees, 45 degrees, and 60 degrees of flexion using a robotic/universal force-moment sensor testing system. ITB forces of 0, 22, 44, and 88 N were also applied. An 88 N ITB force significantly decreased coupled anterior tibial translation of ACL deficient knees by 32%-45% at high flexion angles, but did not have a significant effect at low flexion angles. Further, an 88 N ITB force significantly decreased in situ forces in the ACL at all flexion angles by 23%-40%. These results indicate that during the pivot shift test, the ITB can improve tibial reduction at high flexion angles while not affecting subluxation at low flexion angles. Additionally, the action of the ITB as an ACL agonist suggests that its use as an ACL graft might hinder knee stability in response to rotatory load.     

Rabbit models of bucket-handle-like meniscal tear

After radial tears were artificially created in the periphery of the middle third of the lateral menisci in Japanese white male rabbits, the menisci were sampled postoperatively at 2, 4, 6, 12 and 24 weeks. We noted that radial tears often progressed to longitudinal tears, and the length of longitudinal tears increased with time. On the other hand, the areas in which radial tears had been artificially created were filled with granulation-like tissue. Radial tears thus created may lead to bucket-handle-like tears of the menisci.     

The pivot shift test is of limited clinical relevance in the arthritic anterior cruciate ligament-deficient knee

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.     

Meniscal rasping for repair of meniscal tear in the avascular zone.

We examined experimentally whether a longitudinal tear in the avascular zone of a rabbit meniscus can be healed by meniscal rasping. A full-thickness longitudinal tear 5-mm long was artificially created in the avascular zone of the anterior segment of both medial menisci. Meniscal rasping was then done on the femoral surface of the right meniscus from the parameniscal synovium to the inner segment including the tear. The left meniscus was left without further treatment as control. Two to 4 weeks after surgery, the hypertrophic synovium was observed invading from the parameniscal region to the injured portion. Eight to 16 weeks after surgery, the tear was almost completely healed. In contrast, neither hypertrophy of the synovium covering the tear nor healing was induced in the control meniscus. The mechanical test showed that there was a significant difference in the tensile strength and the stiffness of the injured portion between the rasped meniscus and the control meniscus. Meniscal rasping is easy to do, is effective, and causes few adverse effects with menisci. This procedure may be a treatment option for clinical cases of meniscal tear in the avascular zone for which we have no effective and clinically applicable methods at present, although further investigation is needed before clinical application.     

关节镜下穿刺针改良缝合修复技术在治疗半月板纵行撕裂伤病例中的对照观察

目的:比较关节镜下穿刺针改良缝合技术和Fast-Fix 全内技术在缝合修复半月板纵行撕裂患者中的治疗效果.方法:回顾性研究2016 年7 月至2017 年7 月行半月板缝合修复手术的半月板纵行撕裂患者,穿刺针改良缝合组91 例,Fast-Fix 组77 例.两组患者年龄分别为(26.7±7.6)岁与(27.9±6.1)...     

The Leclercq test in diagnosis of tear in the rotator cuff

The authors report their experience in using the Leclercq test to diagnose tear in the rotator cuff of the shoulder. When positive, this test consists in a radiographic demonstration of reduction in the subacromial space in opposing abduction of the shoulder. Twenty-five patients affected with chronic painful shoulder and suspected lesion of the rotator cuff were submitted to the Leclercq test and subsequently to arthrography in order to evaluate the conditions of the cuff. In all of the cases where the cuff was whole, and arthrography normal, the Leclercq test was negative. When lesion of the cuff was revealed by arthrography, the test was positive in 75% of the cases considered globally, and in 92% of the cases with complete tear in the rotator cuff.     

PCL tibial avulsion with an associated medial meniscal tear in a child: a case report on diagnosis and management

Posterior cruciate ligament (PCL) injuries from tibial avulsions are rare in the paediatric setting. One would need a high index of suspicion as clinical examination may be difficult, especially in the early period. Magnetic resonance imaging is an excellent diagnostic modality for this condition and other associated injuries within the knee. We report a rare case in which the patient had a PCL avulsion off the tibial insertion site with an associated posterior horn medial meniscal tear off the posterior capsule. He was treated through open reduction and internal fixation of the avulsed fragment with suture repair of the meniscal tear. We emphasize the importance of diagnosing and managing associated intra-articular injuries when dealing with the rare condition of PCL tibial avulsion in the paediatric setting.     

关节镜下半月板部分切除术治疗中老年人内侧半月板损伤

目的：探讨关节镜下半月板部分切除术治疗中老年人内侧半月板损伤的临床疗效及其临床价值.方法：自2010年10月至2012年10月,对49例符合纳入标准的膝关节内侧半月板损伤患者,通过关节镜下半月板部分切除术进行治疗.其中男31例,女18例;年龄50～60岁,平均（55.3±2.8）岁;左膝22例,右膝27例.49例平均屈曲角度（116.01±12.03）°.术前膝关节HSS功能评分平均48.73±8.43,Lysholm评分平均63.95±5.45.均采用标准半月板部分切除术,切除损伤部分半月板,遗留前方正常半月板组织.结果：所有手术成功,无严重并发症.术后随访12～36个月,无失访病例.所有患者保持5级肌力,膝关节活动度正常,能完全伸直及完全屈曲.49例平均屈曲角度（136.77±18.56）°,较术前提高（t=17.56,P=0.001）;终末随访膝关节HSS功能评分86～95分,平均90.17±4.10,较术前提高（t=12.65,P=0.001）;Lysholm评分82～91分,平均87.84±5.16,较术前提高（t=13.45,P=0.001）.结论：关节镜下半月板部分切除治疗中老年人单纯内侧半月板损伤疗效优良.严格掌握适应证是保证疗效的前提,精确的手术技术是保证疗效的关键.术后短期内部分患者存在膝关节活动受限,但经过治疗及康复均能完全恢复.     

关节镜下半月板缝合术治疗中年人半月板损伤的疗效评估

目的:观察关节镜下半月板缝合术治疗中年人半月板损伤的临床疗效及愈合情况。方法 :自2014年3月至2015年1月,对40例符合纳入标准的中年膝关节半月板损伤患者采用关节镜下半月板缝合术进行治疗,男24例,女16例;平均年龄(52.65±3.63)岁(50~60岁);左膝28例,右膝12例;屈曲角(117.50±7.16)°(110°~130°)。术前膝关节Lysholm评分54.30±14.72(23~71分),IKDC评分50.65±15.95(18~78分),WOMAC评分23.80±19.39(2~75分)。均采用关节镜下全关节内半月板缝合术,术后以临床评分及MRI检查来评估疗效。结果:所有手术成功,未见严重并发症。术后随访6~12个月,无失访病例。所有患者保持5级肌力,膝关节活动度正常,能完全伸直及完全屈曲。40例平均屈曲角(125.00±5.13)°(110°~130°),较术前改善(t=-3.47,P=0.003)。终末随访膝关节Lysholm、IKDC及WOMAC评分分别为79.50±8.70(t=-7.790,P=0.000),79.40±10.40(t=-8.431,P=0.000),8.15±6.77(t=3.988,P=0.001),均较术前改善。MRI随访完全愈合4例,部分愈合22例,未愈合14例。损伤较小缝合3针及以下者,不愈合率为27.3%(6/22);损伤较大缝合大于3针者,不愈合率为44.4%(8/18)。结论:关节镜下半月板缝合术治疗中年人单纯半月板损伤疗效良好。术后不愈合率达35%,中年人半月板愈合能力较差。损伤较小者愈合率相对较高,损伤越大愈合率越低。     

Chondropathy after meniscal tear or partial meniscectomy in a canine model.

A primary goal in considering treatment for meniscal injuries is the preservation of the health of the articular cartilage. However, the chondroprotective effects of various techniques for meniscal injury treatments are unknown. We used a canine model to quantify articular cartilage degeneration in the medial compartment of the canine knee, resulting from a surgically created tear or a partial meniscectomy (PM) of the posterior region of the medial meniscus (each group, n = 10). After sacrifice at 12 weeks, the development of gross chondropathy and the changes in cartilage tensile stiffness were quantified, and correlations between these measurements were examined. Both treatment surgical treatment groups caused significantly greater gross chondropathy as compared to the unoperated contralateral controls. Cartilage tensile stiffness was significantly lower than unoperated controls by nearly 28% in both experimental groups. However, there were no significant differences observed between the gross chondropathy or the cartilage mechanical property changes between the experimental groups. Importantly, the severity of gross chondropathy was found to significantly correlate with the decrement in tensile stiffness properties of the articular cartilage. These findings indicate that significant degeneration of canine articular cartilage develops to a similar degree in the presence of a partially healed meniscus tear or a PM of the knee.     

Axial alignment of the lower limb in patients with isolated meniscal tear

Meniscal tears do not always result from trauma. To elucidate other factors responsible for meniscal tears, we evaluated the axial alignment of the lower limb in 385 patients (385 menisci) with isolated meniscal tear who were examined between 1972 and 1994. The patients were aged 50 years or less and had no ulceration or defect of articular cartilage of the knee when examined arthroscopically. Of the 385 menisci, 90 were lateral complete discoid; 110, lateral incomplete discoid; 68, lateral semilunar; and 117, medial semilunar. Patients in each of these four groups were divided into four subgroups according to sex and whether there was an obvious history of trauma. The so-called Mikulicz's mechanical axis of the affected side was utilized to evaluate the alignment. The axial alignment of the lower limb was normal in the patients with isolated tears of lateral complete discoid meniscus, lateral incomplete discoid, or lateral semilunar. It appeared that the axial alignment of the lower limb did not have a relationship with the occurrence of these tears. Patients with isolated tears of medial semilunar meniscus without obvious trauma, showed varus deformity of the knee. This deformity appeared to be closely related to the presence of medial meniscal tear. Received for publication on April 23, 1997; accepted on Sept. 9, 1997