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Preoperative knee laxity measurements predict the achievement of a patient-acceptable symptom state after ACL reconstruction: a prospective multicenter study
  1. The PIVOT Group
    1. 1 Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
    2. 2 Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
    3. 3 Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
    4. 4 Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
    5. 5 Istituto Ortopedico Rizzoli, Bologna, Italy
    6. 6 Kobe University, Kobe, Japan
    1. Correspondence to Eric Hamrin Senorski, Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Mölndal SE-431 80, Sweden; eric.hamrin.senorski{at}


    Objective To determine whether patient-related factors, concomitant injuries and preoperative knee laxity could predict a patient acceptable symptom state (PASS) in the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) at 1 and 2 years follow-up after anterior cruciate ligament (ACL) reconstruction in a multicentre cohort.

    Methods Patients between 14 and 50 years of age who underwent single-bundle ACL reconstruction with hamstring tendon autograft within 1 year from the index injury were eligible. Additionally, only patients who completed the IKDC-SKF questionnaire at 1 or 2 years of follow-ups were included. Preoperative knee laxity assessment of patients in the awake state was performed using rolimeter, the Lachman and the pivot-shift test. The pivot shift was graded according to the IKDC criteria and also quantified by the use of non-invasive technology for (1) lateral tibial translation and (2) tibial acceleration. The quantitative pivot shift (QPS) was examined in the awake state and under anaesthesia (EUA). Univariable logistic regression models were performed with achieving PASS in the IKDC as the dependent variable.

    Results A total of 86 patients had complete data on the IKDC-SKF score at 1-year follow-up, of which 67 patients (77.9%) achieved PASS (age 24.8±9.3 years, 43% females). Two-year data were available for 50 patients, of which 39 patients (78.9%) achieved PASS (age 23.9±9.2 years, 42.0% females). A low-grade manual pivot shift according to IKDC grading had increased odds of achieving PASS at 1 year (OR=2.96 (95% CI 1.01 to 8.66), P<0.05) compared with patients who displayed a high-grade pivot shift preoperatively. However, this was not confirmed by the preoperative QPS measures (awake: tibial translation; OR=0.99,(95% CI 0.72 to 1.35), (n.s.), acceleration; OR=1.04,(95% CI 0.68 to 1.59), (n.s.) EUA: tibial translation; OR=1.02 (95% CI 0.78 to 1.31), (n.s.), acceleration; OR=1.14 (95% CI 0.93 to 1.40), (n.s.)). None of the studied variables of patient characteristics, concomitant injuries or knee joint laxity predicted PASS at the 2-year follow-up.

    Conclusion Almost four in every five patients were able to achieve PASS 1 and 2 years after anatomic single-bundle ACL reconstruction. The presence of preoperative low-grade pivot shift increased the odds of achieving an acceptable level of knee function 1 year after ACL reconstruction compared with high-grade pivot shift; however, QPS did not confirm achievement of PASS in this study.

    Level of evidence Level III, prospective cohort.

    • ACL / PCL
    • outcome studies
    • physical examination
    • instability
    • knee
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    • Contributors EHS and ES have substantial contributed to the acquisition of data, analysis of data, and are responsible of drafting the work and revising it critically for important intellectual content. DS, VM and KS have substantial contributed to the acquisition of data, analysis of data, critically revising the work for important intellectual content. RK, SZ and JK have done large contributions to revise and design the manuscript. All authors have given their final approval of the manuscript to be published. In addition, all authors are in agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    • Funding The study was funded through a grant from the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine and the Orthopaedic Research and Education Foundation (research grant No. 708661).

    • Competing interests The PIVOT Shift Application developed in collaboration with James Irrgang was recently licensed by a group of investigators, negotiated through the Innovation Institute. We continue to conduct research to provide validity evidence from the application. The PIVOT group received a grant for the study from the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine. RK reports personal fees from Medacta International, personal fees from Arthrex, personal fees from B. Braun Aesculap Japan, personal fees from Zimmer Biomet, personal fees from Arthrex Japan G.K., personal fees from Smith & Nephew KK, personal fees from Johnson & Johnson K.K., grants from Stryker Japan K.K., grants from Zimmer Biomet, grants from Smith & Nephew Orthopedics K.K., grants from Astellas Pharm, grants from Chugai Pharmaceutical Co., grants from Taisyo Toyama Pharmaceutical Co. and grants from Pfizer Japan, outside the submitted work.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Collaborators PIVOT Study Group: Musahl V, Irrgang JJ, Fu F, Popchak A, Araujo P, de Sa D, Patel N, Lian J (Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA); Kuroda R, Hoshino Y, Kurosaka M, Nagamune K (Kobe University, Kobe, Japan); Zaffagnini S, Muccioli GMM, Signorelli C, Lopomo N, Grassi A (Istituto Ortopedico Rizzoli, Bologna, Italy); Samuelsson K, Karlsson J, Sundemo D, Svantesson E, Senorski EH (Sahlgrenska University Hospital, Gothenburg, Sweden).

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