Pivot Shift Revisited
John P. Albright MD
April 5, 2007
Failed ACL reconstruction
]
Assessment of failure
]
Management
Assessment
]
Causes of failure?
]
Poor primary surgical technique
]
Traumatic event
]
Predisposing factors
Technique Failures
Predisposing factors
]
Graft inadequate
]
Allograft
]
Poor tissue
]
Failure to incorporate
]
Autograft
]
Inadequate size
]
Fixation poor
Predisposing factors
]
Graft inadequate
]
Skeletal architecture
]
Coronal plane
]
Genu Varum
]
Saggital plane
]
Posterior slope
Tunnels misplaced
]
Femur
]
Too anterior tight in flexion
]
Tibia
]
Too anterior tight in extension
MS x-rays
]
18 y/o football player
]
ACL (B-PT-B) good for 18 months
]
Gradual onset (no single episode)
]
Lachman’s test = 4 mm
]
Pivot shift = “+”
]
ALRI grade III (Noyes)
“Over-the-top” Procedure
Original tunnel
Slightly anterior
Physical Exam
]
Re-asses patholaxity
]
Anterior/Posterior only
]
ALRI?
]
PLRI?
]
Varus laxity
]
Valgus laxity
Noyes exam (90 and 30)
]
Neutral
]
External Rot
]
Internal Rot
ITB deep fibers torn also (Terry)
The Horseshoe
Lachman’s
]
Small laxity
]
AP only
]
Internal Rotation??
Lachman’s
]
Gross laxity
Krackow’s
stabilization
]
(neutral rotation)
Losee “Sling & Reef”
Management Program
]
Non surgical
]
Surgery
Non surgical Rehab of the Failed
ACL Reconstruction
]
Try it before 2nd
surgery
]
May allow patient to avoid surgery
]
Motor training may protect 2nd
graft
]
Failure leads to surgery
Goals
Optimizing Control
… with intensive rehab program
Basic Requirements
]
Therapist familiar with low profile pivot shift maneuver
]
Selected patient
]
Motivated
]
Compliant
]
Passes screening protocol
]
Agrees to contract for surgery
Test Proprioception
]
Good
….. no brace
]
Poor
……brace
]
……Surgery?
ACL Rehabilitation Program
]
Understand mechanism
]
Hamstring strengthening
]
Hamstring control
Teach Hamstring Control?
Control Program
]
Identify dangerous maneuver
]
Control with biceps femoris
]
Practice maneuver
]
General agilities
]
Sport specific activities
Goals of Antagonists
Unstable knee
]
Stabilize skeletal components
]
neutralize deforming forces
]
avoid ligament injury
]
Protect articular surfaces
]
equalize pressure distribution
]
prevent focal damage
]
Prolong joint function
Pivot Shift Program Revisited
Profile
]
USA Ortho Sports Medicine MD
]
AOSSM member survey 98
]
ABOS Part II examiner 75-07
No Surgery?
]
WARNING -- “Beginning of the End”
]
“Recurrent pivot shifts”
]
“Meniscus tears”
]
“Increasing laxity”
]
“Arthritis”
Risk of Reinjury
]
Army Outcomes Database
]
Active Duty ACL’s (90-96) = 6,567
]
Surgery 3762 (57%)
]
No Surgery 2814 (43%)
# Meniscus/cartilage re-injury
]
ACL reconstr: 1.56/100 person yrs
]
ACL deficient 1.67/100 person yrs
(p= .001)
Conclusions
]
“ACL reconstruction is protective for”
]
Medial meniscus
]
Lateral Meniscus
]
Articular Surface
“Beginning of the End of the Knee”
No Surgery?
]
ADVICE
]
Strengthen
]
Avoid dangerous activity
]
Brace for sports
]
PRN return
…when surgery desired
ABOS oral examination
]
Favorite question: What strengthening or other rehab program
do you recommend?
]
Usual answer: Quad strengthening
]
(Wrong choice)
Iowa ACLDK Program…
…25 years later
]
100-200/year surgical reconstructions
]
10-20/year “no surgery”
Non Op ACLDK
Patient profile
]
Too old/chronic
]
Failed or loose surgery
]
Too young
]
Athlete in season
UI non-surgery treatment options
]
Brace or surgery
]
Learn to live with it
]
Limit activity
]
Strengthen
]
Hamstrings > quads
]
Train hamstrings for active
control
]
“Smoking gun” contract for surgery
Reflections
]
Review of program evolution
Disability from sports is
primary reason for ACL surgery
Daniel AJSM 94
Kaiser-Permanente Study
Prospective
Descriptive
Many ACLDK continued to play
sports without surgery
Daniel 94
Greater incidence of arthrosis in
reconstructed knees with normal menisci
ACLDK Functional Outcome & Joint Laxity
]
“Copers” vs Non-copers
]
Laxity equal
]
IKDC equal
]
Functional scores different
ACLDK
Functional Outcome & Joint Laxity
]
Copers vs Non-copers
]
No correlation
]
Laxity
]
Function
Why no correlation laxity – function?
]
Non surgical pts
]
Post surgical results
]
Hamstrings vs. patellar tendon
]
Hamstring control patterning!
UI Study #1: Descriptive
]
ACLDK
]
38 athletes
“Super Copers”
]
Competitive Athletes
]
High school
]
College
]
Olympic
]
Professional
“Beginning of the End of Knee?”
Knee Instability Findings - ALRI
Knee Instability Findings - ALRI
Predictive Factors
Functional Rating
]
Re-Injury pattern
]
Hamstring control
]
Ability to cut
]
Thigh size
]
Tibial-femoral crepitus
Predictive Factors
Functional Rating
]
Re-Injury pattern
]
Hamstring control
]
Ability to cut
]
Thigh size
]
Tibial-femoral crepitus
Evaluation of Pivot Shift Control
]
No control
]
Partial voluntary control
]
Complete voluntary control
]
Automatic reflexive control
Evaluation of Pivot Shift Control
]
No control
]
Partial voluntary control
]
Complete voluntary control
]
Automatic reflexive control
Evaluation of Pivot Shift Control
]
No control
]
Partial voluntary control
]
Complete voluntary control
]
Automatic reflexive control
Predictive Factors
Functional Rating
]
Injury pattern
]
Hamstring control
]
Ability to cut
]
Thigh size
]
Tibial-femoral crepitus
Predictive Factors
Functional Rating
]
Injury pattern
]
Hamstring control
]
Ability to cut
]
Thigh size
]
Tibial-femoral crepitus
Predictive Factors
Functional Rating
]
Injury pattern
]
Hamstring control
]
Ability to cut
]
Thigh size
]
Tibial-femoral crepitus
Study #2
]
Hamstring control program
]
UI athletes
Study #2 - Results
]
85% success
Study #3
]
Hamstring control program
]
General population
]
15% success
]
patients still trainable
Study #3 - Conclusion
]
Rehab program is…
demanding
unforgiving
Study #4
Sudden spinal load descriptive study
]
9 ACLDK’s
]
9 controls
Study #4
Functional ratings
]
SF36
]
Mohtadi Quality of Life
]
IKDC
]
Modems Lower Extremity Module
Study #4
Results: Backwards pull
]
Normals fire hamstrings 1st
]
ACLDK fire quads 1st
]
Best patients fire hamstrings 1st
Study #4
Results: Injured group
]
Poor lateral instability
]
Quads contract first
]
Long hamstring delay
]
“+” control level correlation
]
% MVC higher
Study #5
]
Consecutive patients
]
Grade level of control
]
Functional performance tests
]
Hamstring control program
]
Repeated measures
Study #5
Functional Outcomes Study
]
John Albright
]
Stephanie Nash
]
Richard Evans
Methods + Materials
]
18 patients
]
Consecutive series
]
Not randomized
]
Outcome measurements
]
Questionnaires
]
Performance tests
]
Exams
Protocol
]
Grade ability to hide pivot
]
Evaluate proprioception sensitivity
]
Obtain function level
]
Outcome measures
]
Performance tests
]
Begin program
Results
]
Program duration
]
6-12 weeks (18-30 sessions)
]
17 completed program
]
1 quit after few sessions
Results: of 16 completing program
13 successful return to desired activity
]
3 elite level
]
2 worse outcome after treatment
]
1 requested surgery after 3 years
Results: of 17 completing program
16 successful return to desired activity
]
10 remain active
]
1 requested surgery
]
1 meniscus tear after 3 years
]
Level 1 volleyball
]
4 postponed surgery
]
2 sports
]
2 skeletal maturity
Results: of 17 completing program
]
2 worse after treatment
]
Both aggravated arthritis pain
]
Both were failed reconstructions
]
1 requested surgery after 3 years
]
Fair-good function level
]
Remained “uneasy”
Results
]
Mohtadi Scores
]
Total group:
]
Pre-Tx: 44.3 (17-80)
]
Post Tx: 82.1 (57-98)
]
14 successes
]
Ave 32 point improvement
Results (preliminary)
]
“Hamstring control” level correlated
]
Mohtadi scores
]
Performance test scores
]
Proprioceptive sensitivity related to
]
Improvement (pre Vs post Tx)
conclusions
]
Quality of life can be improved
]
Patient selection important
]
Success predictable
]
Proprioceptive sensitivity
]
Level of hamstring control achieved
]
Progress displayed in initial sessions