Section VI: Malalignment and Ligamentous Injury   |    
The Pivot-Shift Phenomenon During Computer-Assisted Anterior Cruciate Ligament Reconstruction
Andrew D. Pearle, MD1; Daniel Kendoff, MD1; Volker Musahl, MD1; Russell F. Warren, MD1
1 Sports Medicine and Shoulder Service, Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for A.D. Pearle: pearlea@hss.edu
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Feb 01;91(Supplement 1):115-118. doi: 10.2106/JBJS.H.01553
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Anterior cruciate ligament reconstruction was one of the first procedures in which computer-assisted techniques were used in orthopaedic surgery. However, the use of navigation for tunnel placement in anterior cruciate ligament surgery remains problematic, as the optimal position for placement of the tunnels is debatable. The technical specification of tunnel position is clinically relevant, but the targets and tolerances for this technical specification are poorly understood. The inability to reliably quantify knee kinematics and stability before, during, or after anterior cruciate ligament reconstruction remains a problem. A navigated examination to assess knee stability could potentially close the computer-assisted surgery treatment loop by providing quantitative feedback about various reconstruction techniques. Recent iterations of navigated examinations for the assessment of stability include even complex pathologic movements, such as those detected with the pivot-shift examination. In this paper, we review conventional stability measurements of the knee and compare them with navigated techniques, with a focus on the navigated pivot-shift examination. In summary, direct intraoperative measurements and quantifications of knee stability, including the pivot-shift phenomenon, are now possible with the use of navigation. Consequently, more reproducible and clinically meaningful quantification of the pivot-shift phenomenon may allow for more accurate evaluation of various anterior cruciate ligament reconstruction techniques in the future.

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