Compressive force and valgus torque are the predominant applied loads during the pivot shift exam: An in vitro study

Despite the clinical utility of the pivot shift exam, the requisite applied forces and torques to elicit a pivot shift remain unclear. The purposes of this study are (1) to identify the greatest forces and torques applied to the knee during the pivot shift exam and (2) to evaluate if the applied loads differ among experienced surgeons.

Three cadaveric hemipelvis-to-toe specimens (ages 53, 36 and 31 years; two males and one female) with no history of knee or hip injury were utilized. The experimental setup consisted of securing the hemipelvis to a mounting frame via an external fixator to simulate patient positioning during the clinical exam. The hemipelvis, femur, and tibia were spatially tracked by motion capture and the applied loads were measured using a 6-axis force-torque sensor. After sectioning the anterior cruciate ligament (ACL), three board-certified sports medicine surgeons then performed the pivot shift exam on each specimen utilizing their preferred technique. Forces (compression-distraction, anterior-posterior, and medial-lateral) and torques (varus-valgus, internal-external rotation, and flexion-extension) applied to the knee joint immediately preceding the reduction of the proximal lateral tibia during each pivot shift exam were calculated.

Compression was the largest applied force averaging 95 N ± 15 N for all surgeons and knees, which was at least 4.5 times greater, on average, than the applied anterior and applied medial tibial forces (p < 0.0001). Valgus was the largest of the three applied torques, averaging 8.5 ± 2.1 Nm. Internal rotation torque was 3.7 times less, on average, than the applied valgus torque (p < 0.0001). Each surgeon applied compressive force. However, anterior force was more variable among surgeons, with one of the three surgeons applying minimal anterior force (p ≤ 0.024). The magnitude of applied torques was similar among examiners (n.s.).

Compressive force and valgus torque were the predominant applied loads during the pivot shift exam. A lower magnitude of internal rotation torque was also applied. The anterior force was not consistently applied among examiners. These data can better inform clinical, cadaveric, and computational studies utilizing the pivot shift exam to assess knee biomechanics and can be used to educate trainees in conducting this complex manoeuvre.

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