***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: A prospect i ve study was undertaken to compare the accuracy of the  Lachman test , anterior drawer test and  jerk test  with the KT1000 knee arthrometer in patients with proven anterior cruciate ligament deficiency . The Lachman and anterior drawer tests were found to be the most accurate indicators of anterior cruciate ligament deficiency . The KT1000 knee arthrometer was found to be totally inaccurate , which precludes its use as an objective measure of anteroposterior laxity of the knee The Losee repair controls rotational subluxation of the lateral femoral condyle , or pivot shift , but does not reliably eliminate Lachman laxity . Despite this surgical limitation , many patients who were operated on continued to do high-dem and activities at the last followup . We hypothesized that Lachman findings alone did not predict poor surgical outcome or progression to osteoarthritis . We report on 87 patients evaluated at an average of 9 years ( range , 5 - 21 years ) postoperatively . Prospect ively collected examinations and radiographic , subjective , and objective outcome measures were recorded and statistically evaluated . The presence of a postoperative pivot shift or residual varus laxity correlated with poor patient subjective evaluations and poor scoring outcomes . Lachman laxity with an absent pivot shift had no correlation with the outcome measures or onset of radiographic progression to osteoarthritis . Meniscectomy , additional knee surgery , increased valgus or varus laxity , and time from injury until the final radiograph positively correlated with the onset of osteoarthritis . Elimination of the pivot shift was necessary to achieve successful relief of symptoms and functional outcome . In the absence of a pivot shift , Lachman laxity was not solely predictive of poor outcomes . Level of Evidence : Prognostic study , Level II-1 ( retrospective study ) . See the Guidelines for Authors for a complete description of levels of evidence We conducted a prospect i ve r and omised study of anatomical single-bundle ( A-SB group ) versus double-bundle ( A-DB group ) anterior cruciate ligament ( ACL ) reconstruction using the hamstrings tendons . Twenty patients with unilateral ACL deficiency were r and omised into two groups . We created the bone tunnels at the position of the original insertion of the anteromedial bundle footprint and posterolateral bundle footprint in the A-DB group and at the central position between these two bundles in the A-SB group . All of the patients were tested before ACL reconstruction and one year after surgery . The KT-1000 measurements , isokinetic muscle peak torque and heel-height difference were evaluated and the general knee condition was assessed by Lysholm score . For pre- and postoperative stability assessment , we used the six-degrees-of-freedom of knee kinematic measurement system using an electromagnetic device ( the EMS ) for quantitative assessment during the Lachman test and the pivot shift test . There were no significant differences in the KT-1000 measurements , isokinetic muscle peak torque , heel-height difference , and Lysholm score at one-year follow-up between these two groups . The EMS data showed there were significant differences in the acceleration of the pivot shift test between the operated knee and the contralateral normal knees in the A-SB group . In conclusion , clinical outcomes were equally good in both groups . However , the EMS data showed the anatomical double-bundle ACL reconstruction tended to be biomechanically superior to the single-bundle reconstruction Purpose Combinations of intra- and extra-articular procedures have been proposed for  anterior cruciate ligament reconstruction  with the aim of achieving an optimal control of translational and rotational knee laxities . Recently , the need for better reproducing the structural and functional behavior of the native anterior cruciate ligament led to the definition of anatomic double-bundle surgical approach . This study aim ed to quantitatively verify whether the in vivo static and dynamic behavior obtained using over-the-top single-bundle with extra-articular tenodesis reconstruction was comparable to the results achieved by anatomic double-bundle approach . Methods Thirty-five consecutive patients , with an isolated anterior cruciate ligament injury , were included in the study .  St and ard clinical laxities and pivot-shift test were quantified before and after anterior cruciate ligament reconstruction by means of a surgical navigation system dedicated to kinematic assessment ; displacements of medial and lateral compartment during stress tests were also analyzed . Results Single-bundle with extra-articular tenodesis approach presented statistically better laxity reduction in varus/valgus stress test at full extension and in internal/external rotation at 90 ° of flexion ; lateral plasty controlled better the lateral compartment during drawer test and varus/valgus stress test both at 0 ° and 30 ° of flexion and both the compartments during internal/external rotation at 90 ° of flexion . On the other h and , pivot-shift phenomenon was better controlled by anatomic double-bundle reconstruction . Conclusions Both the reconstructions worked similarly for static knee laxity .  The extra-articular procedure played an important role in better constraining the displacement of lateral tibial compartment , whereas the anatomic double-bundle reconstruction better restored the dynamic behavior of knee joint highlighted under pivot-shift stress test . Study design Case series Abstract Although magnetic resonance imaging ( MRI ) has improved the diagnostic accuracy of meniscal pathology , the authors believe that physical examination remains essential to the evaluation of knee pathology . In this study , the diagnostic accuracy of five clinical tests for meniscal pathology was prospect ively evaluated in 160 patients , who thereafter underwent arthroscopy .  69 % ( 109 knees ) of the knees tested had associated ACL deficiency . There were 144 meniscal lesions in 130 of the 160 knees which were examined . The sensitivity of the tests was lower than the specificity . Conventional tests such as McMurray and Apley tests showed a low accuracy rate of 45 % and 28 % respectively . The diagnostic value of the axially loaded pivot shift test was significantly higher , indicating that this remains a useful diagnostic aid . Résumé Ils évaluent prospect ivement la précision diagnostique de cinq différentes épreuves cliniques employées pour confirmer des déchirures méniscales chez des 160 sujets ayant subi une évaluation arthroscopique . Soixante – neuf pour cent ( 109 ) des genoux contrôlés par les auteurs présentaient une carence arthrocinétique complexe . Ils ont observé 144 déchirures méniscales sur 130 genoux . Toutes les épreuves cliniques présentaient généralement une sensibilité inférieure à leur spécificité . Quant au test de déplacement du pivot sous charge axiale , le fait que sa valeur diagnostique est , dans l’ensemble , significativement supérieure à celle des autres manoeuvres diagnostiques en fait un supplément de choix dans l’arsenal diagnostique Double-bundle  anterior cruciate ligament ( ACL ) reconstruction reproduces anteromedial and posterolateral bundles , and thus has theoretical advantages over conventional single-bundle reconstruction in controlling rotational torque in vitro . However , its superiority in clinical practice has not been proven . We analyzed rotational stability with three reconstruction techniques in 60 consecutive patients who were r and omly divided into three groups ( double-bundle , anteromedial single-bundle , posterolateral single-bundle ) . In the reconstructive procedure , the hamstring tendon was harvested and used as a free tendon graft . Followup examinations were performed 1 year after surgery . Anteroposterior laxity of the knee was examined with a KT-1000 arthrometer , whereas rotatory instability , as elicited by the pivot shift test , was assessed using a new measurement system incorporating three-dimensional electromagnetic sensors . Routine clinical evaluations , including KT examination , demonstrated no differences among the three groups . However , using the new measurement system , patients with double-bundle ACL reconstruction showed better pivot shift control of complex instability than patients with anteromedial and posterolateral single-bundle reconstruction . Level of Evidence : Level II , therapeutic study . See the Guideline for Authors for a complete description of levels of evidence Clinical evaluation of knee instability is often difficult to reproduce , and several different physical tests have become popular . In an attempt to eluci date reasons for variations in the degree of pivot shift phenomenon seen with the use of the various tests , we have prospect ively evaluated a group of 37 patients with surgically docu mented ACL injuries , noting the effects of hip position and tibial rotation .  The patients were examined under anesthesia  , and the pivot shift was grade d as 0 ( absent , or negative ) , 0.5 + ( trace ) , 1 + , 2 + , or 3 + ( with locking ) . All knees were tested in hip abduction , neutral , and hip adduction , and with the tibia in external and internal rotation , so that six positions were evaluated . Hip position strongly correlated with the degree of pivot shift regardless of tibial rotation . Overall , abduc tion produced the greatest degree of pivot shift , fol lowed by neutral and finally adduction . External tibial rotation increased the pivot shift score in abduction and neutral , but not in adduction . A grading system for the subject population showed that abduction/external ro tation ( ABDER ) result ed in the highest pivot shift scores , and that adduction/external rotation ( ADDER ) and adduction/internal rotation ( ADDIR ) result ed in the lowest scores . Nine patients out of 20 with a 3 + pivot shift in ABDER were negative in ADDER . The pivot shift score was dampened at least one grade from ABDER to ADDER in 92 % of the patients . We conclude that hip position and tibial rotation affect the degree of pivot shift phenomenon , and it is our impression that the iliotibial b and plays a significant role in controlling the degree of pivot shift observed . When examining a knee for ACL insufficiency , it is critical to pay attention to the position of the leg because varia tions in hip position and tibial rotation affect the gra dation of the pivot shift sign and a false negative test may be elicited CLINICAL QUESTION In patients presenting with possible rupture of the anterior cruciate ligament ( ACL ) , which diagnostic test can provide an accurate diagnosis during the physical examination ? DATA SOURCES Two review ers search ed MEDLINE ( 1966 to February 14 , 2003 ) and EMBASE ( 1980 to February 14 , 2003 ) . Articles written in English , French , German , or Dutch were included . The key search terms were knee injuries , knee joint , and knee . These terms were combined with the headings joint instability and anterior cruciate ligament , as well as the text words laxity , instability , cruciate , and effusion . The results of these search es were combined with the subject headings sensitivity and specificity , physical examination , and not ( animal not [ human and animal ] ) . Additional text words search ed were sensitivit * , specificit * , false positive , false negative , accuracy , screening , physical examination , and clinical examination . The reference lists of included articles were examined . STUDY SELECTION Inclusion criteria consisted of ( 1 ) investigation of at least one physical diagnostic test for assessment of ACL ruptures in the knee and ( 2 ) the use of a reference st and ard of arthrotomy , arthroscopy , or magnetic resonance imaging . DATA EXTRACTION Two independent review ers extracted data from each included study . The method ologic quality of each test was assessed and recorded on a checklist for the screening of diagnostic tests ( www.cochrane.de/cochrane/sadtdoc1.htm ) . The 3 diagnostic tests vali date d in this review were the pivot shift test , the anterior drawer test , and the Lachman test . A summary receiver operating characteristic curve was performed for each test , and the sensitivity , specificity , and predictive values were reported . MAIN RESULTS The search strategy produced 1090 potentially eligible studies , of which 17 studies were selected . One study was included via reference list examination and 2 reports referred to the same study . Thus , 17 studies met the inclusion criteria and were used for this review . For the included studies , the sample size ranged from 32 to 300 patients . As for the age of the subjects , the authors of 4 studies failed to report it . Thus , the average age of patients across 13 of the 17 studies was 28.6 years . Authors of all studies failed to measure the clinical test and reference st and ard separately and with blinding . In addition , all but two studies had a significant degree of verification bias . Arthrotomy was the lone reference st and ard in 4 studies whereas arthrotomy/arthroscopy was the reference st and ard in 5 studies . Arthroscopy alone was the reference st and ard in 6 studies where only 2 studies used MRI as the reference st and ard . Authors of 8 studies examined the anterior drawer test and reported sensitivity values ranging from 0.18 - 0.92 and specificity values ranging from 0.78 - 0.98 . When pooled together using the bivariate r and om effects model ( BREM ) , the sensitivity value of the 8 studies was 0.2 and the specificity value was 0.88 . Authors of 9 studies examined the Lachman test  and reported sensitivity values ranging from 0.63 - 0.93 and specificity values ranging from 0.55 - 0.99 . Pooled together using the BREM , the sensitivity value was 0.86 and the specificity value was 0.91 . Lastly , authors of 6 studies examined the pivot shift test and reported sensitivity values ranging from 0.18 - 0.48 and specificity values ranging from 0.97 - 0.99 . Data for the pivot shift test could not be pooled using the BREM because of the low number of available studies . Predictive values were reported graphically , with the pivot shift test having the highest positive predictive value and the Lachman test having the best negative predictive value . CONCLUSIONS Based on predictive value statistics 
    Output:
    
The pivot shift test has been quantified by means of 25 parameters , but most of the studies focused on anterior-posterior translations , internal – external rotation and acceleration in anterior-posterior direction .