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The effect of high-grade preoperative pivot shift test on outcomes of anterior cruciate ligament (ACL) reconstruction surgery is not very well established. The present study was conducted to study the factors associated with high-grade pivot shift test and effect of high-grade preoperative pivot shift test on functional outcomes after ACL reconstruction surgery. Three hundred and sixty-two patients who underwent primary ACL reconstruction surgery were enrolled in the study. The pivot shift test was performed preoperatively under anesthesia in all patients. Side of the meniscal tear, if present at the time of ACL reconstruction, was documented. Patients were divided into two groups depending upon the grade of pivot shift test: group H, high-grade pivot shift ( n  = 84/362; 23%); and group L, low-grade pivot shift ( n  = 278/362; 77%). Patients were further divided into two groups depending upon the duration of injury: acute (&lt;6 months) and chronic (&gt;6 months). The functional assessment was done using Lysholm score and Tegner activity scale. The presence of lateral meniscus tear (27/84 vs. 53/278) or both menisci tear (29/84 vs. 60/278) was associated with high-grade pivot shift ( p  &lt; 0.05). Chronic ACL tears were also observed to be associated with high-grade pivot shift ( p  = 0.03). The mean Lysholm score in group H and group L patients was 93.8 ± 5.1 and 95.2 ± 5.3, respectively ( p  = 0.04). The mean post-op Tegner activity scale in group H was 6.8 and in group L was 7.3 ( p  = 0.0001). Also, 181/253 (71.5%) patients returned to same or higher level of sports activity in group L as compared to 33/72 (46%) patients in group H. The incidence of graft failure in groups H and L was 6.5% (5/77) and 1.6% (4/257;  p  = 0.03), respectively. The high-grade pivot shift is associated with chronic ACL tear (&gt;6 months) and concomitant lateral meniscus tear. The presence of high-grade pivot shift preoperatively is associated with inferior clinical outcomes and lower rate of return to sports. Level IV, case–control study.

The presence of high-grade pivot shift test preoperatively is associated with inferior functional outcomes