Accounting for velocity of the pivot shift test manoeuvre decreases kinematic variability

The pivot shift test is the only clinical test which correlates with knee function following rupture of the ACL. A grade is given to the pivot shift in a subjective manner, leading to efforts to quantify the bone movements and correlate them to the grade. However, the dynamic and unconstrained nature of the manoeuvre introduces important kinematic variability. Our main objective was to develop a method to lessen the variability attributable to clinician technique, therefore increasing inter-grade differences. Three different orthopaedic surgeons each performed the pivot shift test on 12 subjects. Knee joint kinematics were recorded using electromagnetic motion capture devices. Inter-clinician variability was quantified and a method was developed to diminish it, using the angular velocity of flexion. This method was then applied to a larger population composed of 127 knees with various degrees of instability, evaluated by one of eight different orthopaedic surgeons. The clinical grades given by the clinicians were in almost perfect agreement (kappa=0.83). Normalization of kinematic parameters using the angular velocity of knee joint flexion produced by the clinicians reduced the intra-clinician variability by 20%, resulting in an intra-class correlation coefficient (ICC) of 0.52, up from 0.41 before normalization. This allowed for more significant differences between the grades of pivot shift. Simple normalisation of pivot shift kinematics using the angular velocity of flexion reduces clinician-related variability and allows for significant differences between the different grades. These results are an important step towards developing an objective measurement tool for the pivot shift phenomenon.