KNEE Can the pivot-shift be eliminated by anatomic double-bundle anterior cruciate ligament reconstruction? Stefano Zaffagnini • Giulio Maria Marcheggiani Muccioli • Nicola Lopomo • Cecilia Signorelli • Tommaso Bonanzinga • Costanza Musiani • Papakonstantinou Vassilis • Marco Nitri • Maurilio Marcacci Received: 13 December 2011 / Accepted: 10 January 2012 / Published online: 24 January 2012 Ó Springer-Verlag 2012 Abstract Purpose To assess the ability of anatomic double-bundle anterior cruciate ligament reconstruction in eliminating the pivot-shift phenomenon when identified by a quantitative measuring system (computer navigation or magnetic reso- nance imaging). Methods Literature review. Medline, Google Scholar and Cochrane Reviews computerized databases research using the keywords ‘‘pivot-shift,’’ ‘‘anterior cruciate ligament reconstruction’’ and ‘‘double bundle.’’ Twelve (7 in vitro and 5 in vivo) studies met the inclusion criteria. Results There was a wide variation in the absolute value of translation and rotation measured after anatomic double- bundle anterior cruciate ligament reconstruction. There were also differences in fixation methods, pivot-shift exe- cution conditions, applied stresses during the pivot-shift, calculation methods and reference systems utilized by measurement systems. Conclusions The double-bundle reconstruction was shown to over-constrain the knee with respect to the intact value, especially closer to knee extension. This review demonstrated that anatomic double-bundle anterior cruci- ate ligament reconstruction is able to eliminate pathologi- cal translations and rotations during the pivot-shift phenomenon, as identified by quantitative measurement systems. Level of evidence Review of Level III studies, Level III. Keywords Anterior cruciate ligament Á Anatomic Á Double-bundle Á Pivot-shift Á Quantitative assessment Introduction The clinical need for better reproducing the anatomic structure and functional behavior of the native ACL led to the development of new surgical procedures, dedicated to better control rotational and dynamic laxities of the knee [31], and to reproduce the kinematics of the normal joint [38]; this clinical research led to the development of ‘‘double-bundle’’ (DB) ACL reconstructions [4, 6, 21]. Clinical evaluation of the operated knee joint is crucial for the assessment of the success of the surgical technique. Many clinical tests have been described for the evaluation of ruptured or reconstructed ACL. Bull et al. [3] reported that these procedures could allow the assessment of two different types of joint laxities: specifically static and dynamic laxity. The static laxity can be measured, in gen- eral applying a predetermined direct load to the joint and measuring the resultant displacement. The most commonly presented clinical symptom after ACL rupture is often referred to as ‘‘giving way’’ during daily or athletic activity. This symptom is expression of an abnormal dynamic laxity of the knee. In 1972, Galway and MacIntosh [9] firstly described this phenomenon and the clinical test trying to mimic this symptom in order to recreate the ‘‘giving way’’ sensation: this is termed the ‘‘pivot-shift’’ (PS) test. This test was originally described as a clunk produced during the subluxation of the lateral tibial condyle, while the knee was stressed in valgus and internal rotation at 30° of extension. This original description was followed by various different definitions in the next years [1, 8, 11, 14, 20, 22, 26, 36]. All these techniques reproduced the PS phenomenon, even S. Zaffagnini (&) Á G. M. Marcheggiani Muccioli Á N. Lopomo Á C. Signorelli Á T. Bonanzinga Á C. Musiani Á P. Vassilis Á M. Nitri Á M. Marcacci 3rd Orthopaedic and Traumatology Clinic and Biomechanics Laboratory, Codivilla-Putti Research Center, Istituto Ortopedico Rizzoli—University of Bologna, via di Barbiano, 1/10, 40100 Bologna, Italy e-mail: s.zaffagnini@biomec.ior.it 123 Knee Surg Sports Traumatol Arthrosc (2012) 20:743–751 DOI 10.1007/s00167-012-1897-6