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The pivot shift is a dynamic but passive test of knee stability, carried out by the examiner without any activity of the patient. It shows a dysregulation between rolling and gliding in the kneejoint. The patient lies in supine. The movement is a combination of axial load and valgus force, applied by the examiner, during a knee flexion from an extended position. When the test is positive, it indicates an injury of the anterior cruciate ligament. [1](A2)[2](B)

Is the pivot shift test a reliable testThe Pivot Shift test attempts to reproduce the rotary and transalatory instability in an ACL deficient knee. [8] The test has a sensitivity from 0.18 to 0.48 and a specificity from 0.97 to 0.99 for diagnosing an ACL tear. The mean sensitivity and specificity are respectively 0.32 and 0.98. [9] (A1) [10] (A1) [11] (A1) [12] (A1) [13] (A1) Although the test is clinically relevant and reproduces a functional movement of the knee joint, it is difficult to quantify. Recently a study was done using a navigation system to quantify measurements of knee laxity in individuals who underwent ACL reconstruction. The Pivot shift test was reliable with both patient self-assessment of laxity and with surgical performance. [14] This highlights the clinical relevance of the test. Traditionally, the Lachman or the less significant Anterior drawer test were used more often to measure knee laxity due to its quantifiability, however recent advances in technology have allowed for more objective and measurable observations of the motions involved in the pivot shift and may lead to the ability to make the test quanitifiable for research. [15]

For the pivot shift test, the examiner applies with one hand an axial and valgus load. This hand is also going to control the rotational position of the tibia during the test. With the other hand, the foot is held firmly against the examiner. The test can be carried out in three positions of rotation: medial, neutral and lateral rotation of the tibia. (Figs 1,2,3) [2]

Remark: the lateral side of the tibiaplateau is always the most mobile. Table 1 [2](B)The advantage of repeating the test in different positions of rotation is that it gives a more accurate and reproducible way to quantify the test, unlike the subjective estimation of severity. But the downside of this method is that it is not completely objective because the examiner must decide whether or not there is a positive pivot shift test. Except for grade III, there is an important positive difference in accuracy of the test when the estimation is done under anaesthesia. Even under anaesthesia it may be difficult to differentiate grades II and III. Such cases should be treated as grade II.The anterior cruciate ligament is already non-functional from grade II. The difference between grade II and III is that when you have got a grade III, there is additional laxity on both medial and lateral sides. This involves secondary limitation in the posteromedial and posterolateral corners togheter with the purely lateral and medial structures. Certain types of acute injury may prove difficult to grade and other evidence of complete rupture of the anterior cruciate ligament is needed. The lachman test can give a clear grading and will show that the tibial plateau is subluxating. (see table 2 for more information)The Lachman test can be executed on a painful knee. This is not the case for the pivot shift test.

Determine as soon as possible after the start of the inspection whether air contaminant sampling is required by using the information collected during the walk-around (including any screening samples, such as detector tube results) and from the pre-inspection review. To eliminate errors associated with fluctuations in exposure, conduct representative full-shift sampling for air contaminants when determining compliance with an 8-hour time-weighted average (TWA) permissible exposure limit (PEL). Full-shift sampling is defined as a minimum of the total time of the work shift less one hour (e.g., seven hours of an 8-hour work shift or nine hours of a ten-hour work shift). Make every attempt to sample as much of the work shift as possible, including segments of the greatest exposure. However, no more than eight hours of sampling can be used in the 8-hour TWA calculation (for extended work shifts refer to Section III. E.). A representative exposure sample period may be less than seven hours.

Where relatively high airborne concentrations are anticipated, it may be necessary to replace the sampler during the shift to avoid filter overloading and/or sorbent saturation (refer to Section III.D.5.). Before sampling, check the CSI method to determine flow rate and the minimum and maximum sample volumes needed for each sample. Based on the minimum sample volume and flow rate, determine the minimum duration per sampler.

For example, if the minimum sample volume is 240 liters, and the flow rate is 2 liters per minute (L/min), the sampler could be changed out after two hours, and full-shift sampling could be conducted using four two-hour time segments. However, if the minimum sample volume is 600 liters and the flow rate is 2 L/min, a four-hour sample would be insufficient.

For example, OSHA Method ID-100 for ethylene oxide specifies a flow rate of 0.05 L/min and a maximum sample volume of 12 liters. For full-shift sampling it will be necessary to sample in segments of no longer than four hours to avoid exceeding the maximum sample volume (12 liters/0.05 L/min = 240 minutes, or 4 hours).

Strive to sample for at least the minimum sampling time or air volume prescribed in the OSHA CSI file. However, this must be balanced against the need to replace the collection medium when overloading of the sampling medium is anticipated or observed during sampling. Overloading is characterized by saturation of the sampling medium. In the case of filters, overloading may be evidenced by the presence of loose material in the filter cassette, darkening of the filter and/or by a reduction in the sampling pump flow rate. For adsorbent media, overloading occurs when the ability of the sampling medium to effectively collect the analyte is compromised. In practice, overloading is difficult to detect and CSHOs should use their observations, experience, and professional judgment to avoid this adverse sampling situation. In general, overloading can be avoided by replacing the collection medium several times during the work shift (once the minimum sample volumes are achieved.) 153554b96e

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