Standardized pivot shift test improves measurement accuracy

  • Yuichi HoshinoEmail author
  • Paulo Araujo
  • Mattias Ahlden
  • Charity G. Moore
  • Ryosuke Kuroda
  • Stefano Zaffagnini
  • Jon Karlsson
  • Freddie H. Fu
  • Volker Musahl



The variability of the pivot shift test techniques greatly interferes with achieving a quantitative and generally comparable measurement. The purpose of this study was to compare the variation of the quantitative pivot shift measurements with different surgeons’ preferred techniques to a standardized technique. The hypothesis was that standardizing the pivot shift test would improve consistency in the quantitative evaluation when compared with surgeon-specific techniques.


A whole lower body cadaveric specimen was prepared to have a low-grade pivot shift on one side and high-grade pivot shift on the other side. Twelve expert surgeons performed the pivot shift test using (1) their preferred technique and (2) a standardized technique. Electromagnetic tracking was utilized to measure anterior tibial translation and acceleration of the reduction during the pivot shift test. The variation of the measurement was compared between the surgeons’ preferred technique and the standardized technique.


The anterior tibial translation during pivot shift test was similar between using surgeons’ preferred technique (left 24.0 ± 4.3 mm; right 15.5 ± 3.8 mm) and using standardized technique (left 25.1 ± 3.2 mm; right 15.6 ± 4.0 mm; n.s.). However, the variation in acceleration was significantly smaller with the standardized technique (left 3.0 ± 1.3 mm/s2; right 2.5 ± 0.7 mm/s2) compared with the surgeons’ preferred technique (left 4.3 ± 3.3 mm/s2; right 3.4 ± 2.3 mm/s2; both P < 0.01).


Standardizing the pivot shift test maneuver provides a more consistent quantitative evaluation and may be helpful in designing future multicenter clinical outcome trials.

Level of evidence

Diagnostic study, Level I.


Anterior cruciate ligament (ACL) Pivot shift test Electromagnetic measurement system Acceleration measurement Image analysis 



The authors would like to sincerely thank the expert surgeons for their participation and inspiring comments during the study (Drs. Roland Becker, Shiyi Chen, Moises Cohen, Andreas Imhoff, Timo Jarvela, Jon Karlsson, Masahiro Kurosaka, Benjamin Ma, Willem van der Merwe, Philippe Neyret and Robert Smigielski).

Supplementary material

Supplementary material 1 (WMV 5476 kb)


  1. 1.
    Araki D, Kuroda R, Kubo S, Fujita N, Tei K, Nishimoto K, Hoshino Y, Matsushita T, Matsumoto T, Nagamune K, Kurosaka M (2011) A prospective randomized study of anatomic single-bundle versus double-bundle anterior cruciate ligament reconstruction: quantitative evaluation using an electromagnetic measurement system. Int Orthop 35(3):439–446PubMedCrossRefGoogle Scholar
  2. 2.
    Bedi A, Musahl V, Lane C, Citak M, Warren RF, Pearle AD (2010) Lateral compartment translation predicts the grade of pivot shift: a cadaveric and clinical analysis. Knee Surg Sports Traumatol Arthrosc 18:1269–1276PubMedCrossRefGoogle Scholar
  3. 3.
    Bignozzi S, Zaffagnini S, Lopomo N, Fu FH, Irrgang JJ, Marcacci M (2010) Clinical relevance of static and dynamic tests after anatomical double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 18:37–42PubMedCrossRefGoogle Scholar
  4. 4.
    Bull AMJ, Earnshaw PH, Smith A, Katchburian MV, Hassan ANA, Amis AA (2002) Intraoperative measurement of knee kinematics in reconstruction of the anterior cruciate ligament. J Bone Jt Surg Br 84:1075–1081CrossRefGoogle Scholar
  5. 5.
    Fujita N, Kuroda R, Matsumoto T, Yamaguchi M, Yagi M, Matsumoto A, Kubo S, Matsushita T, Hoshino Y, Nishimoto K, Araki D, Kurosaka M (2011) Comparison of the clinical outcome of double-bundle, anteromedial single-bundle, and posterolateral single-bundle anterior cruciate ligament reconstruction using hamstring tendon graft with minimum 2-year follow-up. Arthroscopy 27(7):906–913PubMedCrossRefGoogle Scholar
  6. 6.
    Galway HR, Beaupre A, MacIntosh DL (1972) Pivot shift: a clinical sign of symptomatic anterior cruciate deficiency. J Bone Jt Surg Br 54-B:763–764Google Scholar
  7. 7.
    Galway HR, MacIntosh DL (1980) The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency. Clin Orthop Relat Res 147:45–50PubMedGoogle Scholar
  8. 8.
    Grood ES, Suntay WJ (1983) A joint coordinate system for the clinical description of three-dimensional motions: application to the knee. J Biomech Eng 105:136–144PubMedCrossRefGoogle Scholar
  9. 9.
    Hoshino Y, Kuroda R, Nagamune K, Araki D, Kubo S, Yamaguchi M, Kurosaka M (2011) Optimal measurement of clinical rotational test for evaluating anterior cruciate ligament insufficiency. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-011-1643-5
  10. 10.
    Hoshino Y, Kuroda R, Nagamune K, Nishimoto K, Yagi M, Mizuno K, Yoshiya S, Kurosaka M (2007) The effect of graft tensioning in anatomic 2-bundle ACL reconstruction on knee joint kinematics. Knee Surg Sports Traumatol Arthrosc 15(5):508–514PubMedCrossRefGoogle Scholar
  11. 11.
    Hoshino Y, Kuroda R, Nagamune K, Yagi M, Mizuno K, Yamaguchi M, Muratsu H, Yoshiya S, Kurosaka M (2007) In vivo measurement of the pivot-shift test in the anterior cruciate ligament-deficient knee using an electromagnetic device. Am J Sports Med 35:1098–1104PubMedCrossRefGoogle Scholar
  12. 12.
    Hughston JC, Andrews JR, Cross MJ, Moschi A (1976) Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. J Bone Jt Surg Am 58(2):159–172Google Scholar
  13. 13.
    Jonsson H, Riklund-Ahlström K, Lind J (2004) Positive pivot shift after ACL reconstruction predicts later osteoarthrosis: 63 patients followed 5–9 years after surgery. Acta Orthop Scand 75(5):594–599PubMedCrossRefGoogle Scholar
  14. 14.
    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 32:629–634PubMedCrossRefGoogle Scholar
  15. 15.
    Kubo S, Muratsu H, Yoshiya S, Mizuno K, Kurosaka M (2007) Reliability and usefulness of a new in vivo measurement system of the pivot shift. Clin Orthop Relat Res 454:54–58PubMedCrossRefGoogle Scholar
  16. 16.
    Kuroda R, Hoshino Y, Kubo S, Araki D, Oka S, Nagamune K, Kurosaka M (2011) Similarities and differences of diagnostic manual tests for anterior cruciate ligament insufficiency. A global survey and kinematics assessment. Am J Sport Med. doi: 10.1177/0363546511423634
  17. 17.
    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 43:3080–3084PubMedCrossRefGoogle Scholar
  18. 18.
    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 Surg Sports Traumatol Arthrosc 16(5):487–492PubMedCrossRefGoogle Scholar
  19. 19.
    Larson RL (1983) Physical examination in the diagnosis of rotatory instability. Clin Orthop Relat Res 172:38–44PubMedGoogle Scholar
  20. 20.
    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 436:229–236PubMedCrossRefGoogle Scholar
  21. 21.
    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 Eng. doi: 10.1080/10255842.2011.591788
  22. 22.
    Losee RE, Johnson TR, Southwick WO (1978) Anterior subluxation of the lateral tibial plateau: a diagnostic test and operative repair. J Bone Joint Surg 60:1015–1030PubMedGoogle Scholar
  23. 23.
    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 Surg Sports Traumatol Arthrosc 19(8):1233–1238PubMedCrossRefGoogle Scholar
  24. 24.
    Nafis C, Jensen V, Beauregard L, Anderson P (2006) Method for estimating dynamic em tracking accuracy of surgical navigation tools. In: Progress in biomedical optics and imaging—proceedings of SPIE, vol 6141, p 61410KGoogle Scholar
  25. 25.
    Nakajima H, Kondo M, Kurosawa H, Fukubayashi T (1979) Insufficiency of the anterior cruciate ligament. Review of our 118 cases. Arch Orthop Trauma Surg 95(4):233–240PubMedCrossRefGoogle Scholar
  26. 26.
    Nishimoto K, Kuroda R, Mizuno K, Hoshino Y, Nagamune K, Kubo S, Yagi M, Yamaguchi M, Yoshiya S, Kurosaka M (2009) Analysis of the graft bending angle at the femoral tunnel aperture in anatomic double bundle anterior cruciate ligament reconstruction: a comparison of the transtibial and the far anteromedial portal technique. Knee Surg Sports Traumatol Arthrosc 17(3):270–276PubMedCrossRefGoogle Scholar
  27. 27.
    Noyes FR, Grood ES, Cummings JF, Wroble RR (1991) An analysis of the pivot shift phenomenon. Am J Sports Med 19:148–155PubMedCrossRefGoogle Scholar
  28. 28.
    Pearle AD, Kendoff D, Musahl V, Warren RF (2009) The pivot-shift phenomenon during computer-assisted anterior cruciate ligament reconstruction. J Bone Joint Surg Am 91(Suppl 1):115–118PubMedCrossRefGoogle Scholar
  29. 29.
    Sakai H, Yajima H, Kobayashi N, Kanda T, Hiraoka H, Tamai K, Saotome K (2006) Gravity-assisted pivot-shift test for anterior cruciate ligament injury: a new procedure to detect anterolateral rotatory instability of the knee joint. Knee Surg Sports Traumatol Arthrosc 14(1):2–6PubMedCrossRefGoogle Scholar
  30. 30.
    Slocum DB, James SL, Larson RL, Singer KM (1976) Clinical test for anterolateral rotary instability of the knee. Clin Orthop Relat Res 118:63–69PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Yuichi Hoshino
    • 1
    • 2
    Email author
  • Paulo Araujo
    • 1
  • Mattias Ahlden
    • 3
  • Charity G. Moore
    • 4
  • Ryosuke Kuroda
    • 2
  • Stefano Zaffagnini
    • 5
  • Jon Karlsson
    • 3
  • Freddie H. Fu
    • 1
  • Volker Musahl
    • 1
  1. 1.Department of Orthopaedic SurgeryUniversity of PittsburghPittsburghUSA
  2. 2.Department of Orthopaedic SurgeryKobe UniversityKobe, HyogoJapan
  3. 3.Department of OrthopaedicsSahlgrenska UniversityGöteborgSweden
  4. 4.The Center for Research on Health CareUniversity of PittsburghPittsburghUSA
  5. 5.Laboratorio di Biomeccanica e Innovazione TecnologicaIstituto Ortopedico RizzoliBolognaItaly

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