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No proof for the best instrumented device to grade the pivot shift test: a systematic review

Background The pivot shift test has been representing the current benchmark in the assessment of dynamic knee laxity related to anterior cruciate ligament injury. Recently, clinical evaluation has been supported by the use of several technologies able to quantify the joint kinematics during the test. Objective The main aim of this review was to verify whether the clinical evaluation of dynamic knee laxity can be supported by a standardised instrumented assessment of the pivot shift test, reported in high-quality clinical trials. Data sources Internet search was performed on PubMed database, Web of Science and reference on published manuscripts. Study eligibility criteria No year restriction was used. Articles were included only when written in English and related to search terms (‘pivot shift’ AND ‘assessment’). 3 reviewers independently selected only in vivo studies that reported both the clinical and quantitative assessment of the pivot shift test. Those articles that analysed only clinical parameters were excluded. Synthesis methods Reviewers evaluated the methodological quality of the studies and extracted the data using a defined protocol. Studies were summarised in terms of demographics, methodologies and technologies used to quantify the pivot shift, clinical grading and any reported correlation or statistical difference between the clinical assessment and the instrumented one. Results 9 studies met the inclusion criteria. The literature presented several devices able to quantify the clinical manoeuvre, specifically the electromagnetic system (2 studies), inertial sensors (6 studies) and image analysis device (1 study). Although mainly used by experts, the most widespread methods (7 out of 9 studies) were reported to be those able to quantify the tibial acceleration. Limitations The study results were extremely heterogeneous. Intertester variability in clinical grading limited the possibility of using it to coherently validate the proposed methodologies. However, no ‘gold standard’ methodology for the evaluation of the pivot shift has been established within the clinical context. Conclusions and relevance A standardised methodology and approach for the quantification of the pivot shift, supported by the highest clinical evidence, is still lacking. It is fundamental to define high-quality randomised perspective clinical trials, thus to allow to reach a proper ‘benchmark’ in the assessment of dynamic knee laxity.