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The Pivot Shift

Perspectives on Modern Orthopaedics articles provide an objective appraisal of new or controversial techniques or areas of investigation in orthopaedic surgery.

Dr. Lane is Fellow, Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY. Dr. Warren is Attending Orthopaedic Surgeon, Sports Medicine and Shoulder Service, Hospital for Special Surgery. Dr. Pearle is Assistant Attending Orthopaedic Surgeon, Sports Medicine and Shoulder Service, Hospital for Special Surgery.

Dr. Warren or a member of his immediate family has received royalties from Biomet and Smith & Nephew. None of the following authors or a member of their immediate families has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Lane and Dr. Pearle.

Reprint requests: Dr. Lane, Alabama Orthopaedic Clinic, 3610 Springhill Memorial Drive North, Mobile, AL 36608; cgl@alortho.com.

The Lachman and the pivot shift are the two clinical tests most commonly used to assess instability in the anterior cruciate ligament (ACL)–deficient knee. Because it is quantifiable, the Lachman test has become the benchmark for assessing the success of ACL reconstruction. As a result, surgical techniques have been developed that effectively eliminate anterior laxity of the knee. Recent studies have shown, however, that rotational stability is not always restored after ACL reconstruction. Furthermore, there is mounting evidence that the pivot shift examination correlates with functional instability and patient outcomes better than does any other physical examination test. This test attempts to reproduce the functional combined rotary and translational instability in the ACL-deficient knee. Although the pathologic kinematics of the pivot shift are difficult to measure, recent technological advances have allowed more accurate and objective descriptions of the pivot shift, which have furthered our understanding of the complex motions involved. These advances may lead to a method of quantifying the pivot shift for research purposes and, ultimately, to ACL reconstruction that is tailored specifically to each patient’s objectively measured rotational instability.

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