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. 2021 Apr 6;9(4):23259671211000038.
doi: 10.1177/23259671211000038. eCollection 2021 Apr.

Association of Ligamentous Laxity, Male Sex, Chronicity, Meniscal Injury, and Posterior Tibial Slope With a High-Grade Preoperative Pivot Shift: A Post Hoc Analysis of the STABILITY Study

Lachlan M Batty  1 , Andrew Firth  1 , Gilbert Moatshe  1 , Dianne M Bryant  1 , Mark Heard  1 , Robert G McCormack  1 , Alex Rezansoff  1 , Devin C Peterson  1 , Davide Bardana  1 , Peter B MacDonald  1 , Peter C M Verdonk  1 , Tim Spalding  1 , Alan M J Getgood  1 ; STABILITY Study Group; Kevin Willits  1 , Trevor Birmingham  1 , Chris Hewison  1 , Stacey Wanlin  1 , Andrew Firth  1 , Ryan Pinto  1 , Ashley Martindale  1 , Lindsey O'Neill  1 , Morgan Jennings  1 , Michal Daniluk  1 , Dory Boyer  1 , Mauri Zomar  1 , Karyn Moon  1 , Raely Pritchett  1 , Krystan Payne  1 , Brenda Fan  1 , Bindu Mohan  1 , Gregory M Buchko  1 , Laurie A Hiemstra  1 , Sarah Kerslake  1 , Jeremy Tynedal  1 , Greg Stranges  1 , Sheila Mcrae  1 , LeeAnne Gullett  1 , Holly Brown  1 , Alexandra Legary  1 , Alison Longo  1 , Mat Christian  1 , Celeste Ferguson  1 , Nick Mohtadi  1 , Rhamona Barber  1 , Denise Chan  1 , Caitlin Campbell  1 , Alexandra Garven  1 , Karen Pulsifer  1 , Michelle Mayer  1 , Nicole Simunovic  1 , Andrew Duong  1 , David Robinson  1 , David Levy  1 , Matt Skelly  1 , Ajaykumar Shanmugaraj  1 , Fiona Howells  1 , Murray Tough  1 , Pete Thompson  1 , Andrew Metcalfe  1 , Laura Asplin  1 , Alisen Dube  1 , Louise Clarkson  1 , Jaclyn Brown  1 , Alison Bolsover  1 , Carolyn Bradshaw  1 , Larissa Belgrove  1 , Francis Millan  1 , Sylvia Turner  1 , Sarah Verdugo  1 , Janet Lowe  1 , Debra Dunne  1 , Kerri McGowan  1 , Charlie-Marie Suddens  1 , Geert Declercq  1 , Kristien Vuylsteke  1 , Mieke Van Haver  1
Affiliations

Association of Ligamentous Laxity, Male Sex, Chronicity, Meniscal Injury, and Posterior Tibial Slope With a High-Grade Preoperative Pivot Shift: A Post Hoc Analysis of the STABILITY Study

Lachlan M Batty et al. Orthop J Sports Med. .

Abstract

Background: A spectrum of anterolateral rotatory laxity exists in anterior cruciate ligament (ACL)-injured knees. Understanding of the factors contributing to a high-grade pivot shift continues to be refined.

Purpose: To investigate factors associated with a high-grade preoperative pivot shift and to evaluate the relationship between this condition and baseline patient-reported outcome measures (PROMs).

Study design: Cross-sectional study; Level of evidence, 3.

Methods: A post hoc analysis was performed of 618 patients with ACL deficiency deemed high risk for reinjury. A binary logistic regression model was developed, with high-grade pivot shift as the dependent variable. Age, sex, Beighton score, chronicity of the ACL injury, posterior third medial or lateral meniscal injury, and tibial slope were selected as independent variables. The importance of knee hyperextension as a component of the Beighton score was assessed using receiver operator characteristic curves. Baseline PROMs were compared between patients with and without a high-grade pivot.

Results: Six factors were associated with a high-grade pivot shift: Beighton score (each additional point; odds ratio [OR], 1.17; 95% CI, 1.06-1.30; P = .002), male sex (OR, 2.30; 95% CI, 1.28-4.13; P = .005), presence of a posterior third medial (OR, 2.55; 95% CI, 1.11-5.84; P = .03) or lateral (OR, 1.76; 95% CI, 1.01-3.08; P = .048) meniscal injury, tibial slope >9° (OR, 2.35; 95% CI, 1.09-5.07; P = .03), and chronicity >6 months (OR, 1.70; 95% CI, 1.00-2.88; P = .049). The presence of knee hyperextension improved the diagnostic utility of the Beighton score as a predictor of a high-grade pivot shift. Tibial slope <9° was associated with only a high-grade pivot in the presence of a posterior third medial meniscal injury. Patients with a high-grade pivot shift had higher baseline 4-Item Pain Intensity Measure scores than did those without a high-grade pivot shift (mean ± SD, 11 ± 13 vs 8 ± 14; P = .04); however, there was no difference between groups in baseline International Knee Documentation Committee, ACL Quality of Life, Knee injury and Osteoarthritis Outcome Score, or Knee injury and Osteoarthritis Outcome Score subscale scores.

Conclusion: Ligamentous laxity, male sex, posterior third medial or lateral meniscal injury, increased posterior tibial slope, and chronicity were associated with a high-grade pivot shift in this population deemed high risk for repeat ACL injury. The effect of tibial slope may be accentuated by the presence of meniscal injury, supporting the need for meniscal preservation. Baseline PROMs were similar between patients with and without a high-grade pivot shift.

Keywords: anterior cruciate ligament; hyperextension; instability; knee; laxity; pivot shift.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: This study was funded by an ISAKOS/OREF grant (2014; International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine/Orthopaedic Research and Education Foundation). R.G.M. has received speaking fees from Bioventus, Pendopharm, Sanofi, and Smith & Nephew. T.S. has received consulting fees from Conmed and speaking fees from Conmed, Joint Operations, and Smith & Nephew. P.C.M.V. has received consulting fees from Conmed and speaking fees from Conmed and Smith & Nephew. A.M.J.G. has received consulting fees from Olympus, Ossur, and Smith & Nephew and royalties from Graymont and Smith & Nephew. L.A.H. has received consulting fees and speaking fees from Conmed. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
Tibial slope measurement technique. A line passing through the middle of the 2 circles is defined as the longitudinal axis of the tibia. Another line is drawn from the most anterior to the most posterior point of the medial tibial plateau. The tibial slope is calculated as 90° minus the acute angle formed by these 2 lines; in this patient, it is 7.1°.
Figure 2.
Figure 2.
Receiver operating characteristic (ROC) curve for predictors of a high-grade pivot shift. The area under the curve is 0.70.
Figure 3.
Figure 3.
Receiver operating characteristic (ROC) curves for predictors of a high-grade pivot shift. Models predicting high-grade preoperative pivot: (A) 355 patients without knee hyperextension as part of their Beighton scores (area under the curve, 0.65) and (B) 193 patients with knee hyperextension as part of their Beighton scores (area under the curve, 0.75).
See this image and copyright information in PMC

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