The Need for an Objective Measurement In Vivo of Rotational Stability of the ACL-Deficient Knee: How Can We Measure It?

  • Vicente Sanchis-Alfonso
  • Franceska Zampeli
  • Andrea Castelli
  • José María Baydal-Bertomeu
  • A. D. Georgoulis


Rotational stability plays a key role in restoring normal function of the knee after anterior cruciate ligament (ACL) reconstruction [15]. Therefore, the accurate evaluation of rotational stability would be an important outcome indicator of ACL reconstruction. The only clinical test for examining rotational stability of the knee is the pivot-shift test [46]. Most surgeons now recognize the importance of the pivot-shift test. A positive pivot-shift test, regardless of the grade, is indicative of a functionally deficient ACL and remains the sine qua non indication for surgery [13]. Moreover, it is predictive of poor subjective and objective outcome, patient discomfort, disability, failure to return to previous level of sport, increased scintigraphic activity in the subchondral bone, and development of osteoarthritis of the knee at long term [20, 21, 24, 50]. Therefore, accurate assessment of the pivot-shift phenomenon is clinically mandatory. However, currently, the gold standard for evaluation of rotational knee stability after ACL tears in the office is based on patient history and subjective un-instrumented physical examination, the pivot-shift test, which is highly variable and dependent on examiner’s skill and experience and has both a low sensitivity and low interobserver reliability [32]. Moreover, the rotational load applied to the knee during the pivot-shift test is much lower than the load applied to the knee during sports activities. Furthermore, patient guarding can lead to false negatives. Moreover, clinical pivot-shift test cannot evaluate small rotational differences between the pathological/reconstructed and the healthy contralateral knee. Finally, the pivot-shift test is often only testable during examination under anesthesia. In our series, the sensitivity of the physical examination with the patient awake was 37.5 %, whereas the sensitivity of the physical examination with the patient under general anesthesia was 87.5 % [42]. Therefore, a negative clinical pivot-shift test does not necessarily involve a normal rotational stability. Currently, however, there is no simple, commercially available device to measure knee rotational stability in vivo.


Anterior Cruciate Ligament Anterior Cruciate Ligament Reconstruction Anterior Cruciate Ligament Injury Pivot Shift Tibial Rotation 
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Copyright information

© Springer-Verlag London 2013

Authors and Affiliations

  • Vicente Sanchis-Alfonso
    • 1
    • 2
  • Franceska Zampeli
    • 3
  • Andrea Castelli
    • 4
  • José María Baydal-Bertomeu
    • 4
  • A. D. Georgoulis
    • 3
  1. 1.Department of Orthopaedic SurgeryHospital Arnau de VilanovaValenciaSpain
  2. 2.Knee Surgery and Arthroscopy UnitHospital 9 de OctubreValenciaSpain
  3. 3.Orthopaedic Sports Medicin Center, Department of Orthopaedic SurgeryUniversity of IoanninaIoanninaGreece
  4. 4.Instituto de Biomecánica de Valencia (IBV)Universidad Politécnica de ValenciaValenciaSpain

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