Rotation of the tibia in the normal and ligament-deficient knee. a study using biplanar photography

The difference between physiological tibial rotation and rotatory instability of the knee, particularly the ‘pivot shift’ phenomenon, was investigated by analysing knee movements under both rotatory and valgus torques using 29 fresh cadaveric knees. The knee movements were measured in three dimensions using biplanar photography, when all ligaments were intact, and then after the ligaments were sequentially sectioned. The axis of the physiological tibial rotation was shown to be located about the centre of the tibial plateaux, while that of the pivot shift is located about the medial collateral ligament (MCL). When the anterior cruciate ligament (ACL) was sectioned, little or no significant change in physiological tibial rotation was observed under rotary torques, while a significant rotatory instability, including the ‘pivot shift’ phenomenon, was observed under a valgus torque. It was thus concluded that the rotatory instability is not simply an increase in the magnitude of the physiological rotation of the tibia, but is an abnormal tibial rotation which occurs with a different mechanism.