1
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Gunepin FX, Letartre R, Mouton C, Guillemot P, Common H, Thoreux P, Di Francia R, Graveleau N. Construction and validation of a functional diagnostic score in anterior cruciate ligament ruptures of the knee in the immediate post-traumatic period. Preliminary results of a multicenter prospective study. Orthop Traumatol Surg Res 2023; 109:103686. [PMID: 37776951 DOI: 10.1016/j.otsr.2023.103686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 10/02/2023]
Abstract
INTRODUCTION Knee ligament injuries are frequent and their number is constantly increasing with the development of sports activities. Dynamic knee maneuvers usually make it possible to diagnose anterior cruciate ligament (ACL) injuries but they remain difficult to perform in the early post-traumatic phase. This leads to the almost systematic use of MRI scans, many of which turn out to be superfluous. The aim of this study was to construct a screening score based solely on history-taking, in order to help diagnose ACL injuries, and to define thresholds that could help inform recommendations for MRI usage. The hypothesis was that this score could distinguish a population of patients with a ruptured ACL from a population of patients with other knee injuries. MATERIAL AND METHODS This prospective multicenter study included 166 patients. Patients were included if they were between 18 and 55 years of age, with knee trauma that had occurred in the last 10 days, and without a bone fracture on standard radiographs. They were excluded if the trauma required immediate surgical management and if they had a history of knee trauma. The screening score was completed by the physician. The score included the following items: assessment of pain, immediate post-traumatic functional impairment, notion of a "pop", feeling of instability and presence of a swelling. An MRI was systematically performed and the patient consulted a referring physician to compare the initial score with the diagnosis. RESULTS Eighty-six patients had an injured ACL and 80 had a healthy ACL. Two thresholds could be identified. For a score lower than 4, the risk of an ACL injury was low with a sensitivity of 96% and a negative predictive value of 87%. For a score above 8, the ACL injury was highly probable with a specificity of 88% and a positive predictive value of 83%. DISCUSSION/CONCLUSION The score was able to distinguish a population of patients with a ruptured ACL from a population of patients with other knee injuries. These preliminary results confirm that the selected items are relevant and that the score can help improve the diagnostic orientation of patients with recent knee trauma. Increasing the sample size in combination with an analysis of influencing factors will determine whether the performance of this score can be refined. LEVEL OF EVIDENCE II prospective multicenter study.
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Affiliation(s)
- François-Xavier Gunepin
- Service de chirurgie orthopédique, clinique Mutualiste de la porte de L'Orient, 3, rue Robert-de-la-Croix, 56100 Lorient, France.
| | - Romain Letartre
- Service de chirurgie orthopédique, hôpital privé la Louvière, Lille, France
| | - Caroline Mouton
- Service de chirurgie orthopédique, centre hospitalier de Luxembourg, clinique d'Eich, Luxembourg, France
| | - Pierrick Guillemot
- Service de médecine du sport, centre hospitalo-universitaire Pontchaillou, Rennes, France
| | - Harold Common
- Service de chirurgie orthopédique, centre hospitalo-universitaire Pontchaillou, Rennes, France
| | - Patricia Thoreux
- Service de médecine du sport, hôpital Hôtel-Dieu, Assistance publique des Hôpitaux de Paris, Paris, France
| | - Rémi Di Francia
- Service de chirurgie orthopédique, centre hospitalo-universitaire de la cavale-blanche, Brest, France
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2
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Sokal PA, Norris R, Maddox TW, Oldershaw RA. The diagnostic accuracy of clinical tests for anterior cruciate ligament tears are comparable but the Lachman test has been previously overestimated: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022; 30:3287-3303. [PMID: 35150292 PMCID: PMC9464183 DOI: 10.1007/s00167-022-06898-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 01/20/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The diagnostic accuracy of clinical tests for anterior cruciate ligament injury has been reported in previous systematic reviews. Numerous studies in these reviews include subjects with additional knee ligament injury, which could affect the sensitivity of the tests. Meta-analyses have also been performed using methods that do not account for the non-independence of sensitivity and specificity, potentially overestimating diagnostic accuracy. The aim of this study was to report the diagnostic accuracy of clinical tests for anterior cruciate ligament tears (partial and complete) without concomitant knee ligament injury. METHODS A systematic review with meta-analysis was performed according to the PRISMA guidelines. Meta-analyses included studies reporting the specificity and/or sensitivity of tests with or without concomitant meniscal injury. Where possible, pooled diagnostic estimates were calculated with bivariate random-effects modelling to determine the most accurate effect sizes. Diagnostic accuracy values are presented for the anterior drawer, Lachman, Lever sign and pivot shift tests overall and in acute or post-acute presentations. RESULTS Pooled estimates using a bivariate model for overall sensitivity and specificity respectively were as follows: anterior drawer test 83% [95% CI, 77-88] and 85% [95% CI, 64-95]; Lachman test 81% [95% CI, 73-87] and 85% [95% CI, 73-92]; pivot shift test 55% [95% CI, 47-62] and 94% [95% CI, 88-97]; Lever sign test 83% [95% CI, 68-92] and 91% [95% CI, 83-95]. For specific presentations, the sensitivity and specificity of the Lachman test, respectively, were: complete tears 68% [95% CI, 54-79] and 79% [95% CI, 51-93]; post-acute injuries 70% [95% CI, 57-80] and 77% [95% CI, 53-91]. CONCLUSIONS The pivot shift and Lever sign were the best tests overall for ruling in or ruling out an anterior cruciate ligament tear, respectively. The diagnostic accuracy of the Lachman test, particularly in post-acute presentations and for complete tears, is lower than previously reported. Further research is required to establish more accurate estimates for the Lachman test in acute presentations and partial ligament tears using bivariate analysis. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Pawel A Sokal
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
- Department of Medicine, School of Medicine, University of Liverpool, Liverpool, L69 3GE, UK
| | - Richard Norris
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
- Department of Trauma and Orthopaedics, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Fazakerley, Liverpool, L9 7AL, UK
| | - Thomas W Maddox
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
- Small Animal Teaching Hospital, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Leahurst Campus, Chester High Road, Neston, CH64 7TE, Wirral, UK
| | - Rachel A Oldershaw
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK.
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3
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Raja AE, Meyer R, Tunis BG, Moreland ML, Tunis JG. Prone Lachman with Ultrasound: A Literature Review and Description of the Technique. Curr Sports Med Rep 2022; 21:336-342. [PMID: 36083709 DOI: 10.1249/jsr.0000000000000992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT Magnetic resonance imaging is the current gold standard imaging modality for diagnosing anterior cruciate ligament (ACL) tears. However, ultrasound has grown in popularity for detecting ACL injuries because of its low cost, portability, and dynamic assessment capabilities. Recent studies demonstrate high sensitivity and specificity for diagnosing isolated ACL tears via ultrasound, but tremendous heterogeneity remains for optimal technique including patient positioning, transducer placement, and dynamic versus static ultrasound usage. As ultrasound becomes ubiquitous in clinics, training rooms, and on the sidelines, identifying objective and sensitive measurements to appropriately screen athletes for significant knee injuries is imperative. This article aims to review the current role of diagnostic ultrasound in ACL injuries and propose a standardized version of the Prone Lachman with Ultrasound test, which is an objective, reliable, and easily reproducible technique to evaluate ACL competency. Developing a standardized protocol will expand the use of point-of-care ultrasound, which may reduce cost and improve efficiency in care.
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Affiliation(s)
- Altamash E Raja
- Primary Care Sports Medicine, Geisinger Wyoming Valley, Wilkes-Barre, PA
| | - Ryan Meyer
- Primary Care Sports Medicine, Geisinger Wyoming Valley, Wilkes-Barre, PA
| | - Brandon G Tunis
- Primary Care Sports Medicine, Geisinger Wyoming Valley, Wilkes-Barre, PA
| | - Michael L Moreland
- Primary Care Sports Medicine, Geisinger Wyoming Valley, Wilkes-Barre, PA
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4
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Evers BJ, Van Den Bosch MHJ, Blom AB, van der Kraan PM, Koëter S, Thurlings RM. Post-traumatic knee osteoarthritis; the role of inflammation and hemarthrosis on disease progression. Front Med (Lausanne) 2022; 9:973870. [PMID: 36072956 PMCID: PMC9441748 DOI: 10.3389/fmed.2022.973870] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
Knee injuries such as anterior cruciate ligament ruptures and meniscal injury are common and are most frequently sustained by young and active individuals. Knee injuries will lead to post-traumatic osteoarthritis (PTOA) in 25–50% of patients. Mechanical processes where historically believed to cause cartilage breakdown in PTOA patients. But there is increasing evidence suggesting a key role for inflammation in PTOA development. Inflammation in PTOA might be aggravated by hemarthrosis which frequently occurs in injured knees. Whereas mechanical symptoms (joint instability and locking of the knee) can be successfully treated by surgery, there still is an unmet need for anti-inflammatory therapies that prevent PTOA progression. In order to develop anti-inflammatory therapies for PTOA, more knowledge about the exact pathophysiological mechanisms and exact course of post-traumatic inflammation is needed to determine possible targets and timing of future therapies.
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Affiliation(s)
- Bob J. Evers
- Department of Experimental Rheumatology, Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
- Canisius Wilhelmina Hospital, Nijmegen, Netherlands
- *Correspondence: Bob J. Evers
| | - Martijn H. J. Van Den Bosch
- Department of Experimental Rheumatology, Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Arjen B. Blom
- Department of Experimental Rheumatology, Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Peter M. van der Kraan
- Department of Experimental Rheumatology, Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | | | - Rogier M. Thurlings
- Department of Experimental Rheumatology, Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
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5
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Dietvorst M, van der Steen MCM, Reijman M, Janssen RPA. Diagnostic values of history taking, physical examination and KT-1000 arthrometer for suspect anterior cruciate ligament injuries in children and adolescents: a prospective diagnostic study. BMC Musculoskelet Disord 2022; 23:710. [PMID: 35883084 PMCID: PMC9317060 DOI: 10.1186/s12891-022-05659-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 07/12/2022] [Indexed: 11/22/2022] Open
Abstract
Background Diagnosing anterior cruciate ligament (ACL) injuries in children and adolescents are more challenging compared to adults. Delayed diagnosis may result in meniscal or chondral injuries. The aim of this study was to determine the diagnostic values of history taking, physical examination and KT-1000 arthrometer for suspect ACL injuries in children and adolescents. Methods In this prospective diagnostic study, all children and adolescents (< 18 years) with post-traumatic knee complaints presenting at the out-patient department of the Máxima MC were eligible for inclusion. One experienced knee specialised orthopaedic surgeon was blinded and performed history taking, physical examination and KT-1000 arthrometer measurement. All patients had a magnetic resonance imaging (MRI) for the final diagnosis. Diagnostic values of interest were sensitivity, specificity, positive and negative predictive values (PPV and NPV). The outcomes of the KT-1000 arthrometer were drafted in a relative operating characteristics (ROC) curve to determine the optimal cut-off points. Results Sixty-six patients were included, of which 50 had an ACL rupture and 16 had no ACL rupture on MRI. Report of a popping sensation during trauma had a specificity and PPV of 100% for diagnosing ACL injuries. The PPV and NPV of the Lachman test (in case of describing end-feel) were 95 and 82%, of the anterior drawer test 87 and 90% and of the pivot shift test 95 and 81% respectively. The optimal cut-off point of the KT-1000 arthrometer at 133 N force was an absolute translation of ≥7 mm with a PPV and NPV of 97 and 88% respectively. Conclusions Report of a popping sensation during trauma has a specificity and PPV of 100% for diagnosing ACL injuries in children and adolescents. Although potentially difficult in children, the Lachman test, anterior drawer test and pivot shift test have a high PPV and NPV when performed by an experienced orthopaedic surgeon. An absolute anterior translation of ≥7 mm of the injured knee in the KT-1000 arthrometer at 133 N has the highest diagnostic values of all tests for diagnosing ACL injuries. Level of evidence 3
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Affiliation(s)
- Martijn Dietvorst
- Department of Orthopedic Surgery and Trauma, Máxima MC, Eindhoven, the Netherlands.
| | - M C Marieke van der Steen
- Department of Orthopedic Surgery and Trauma, Máxima MC, Eindhoven, the Netherlands.,Department of Orthopedic Surgery and Trauma, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Max Reijman
- Department of Orthopedic Surgery, Erasmus University MC, Rotterdam, the Netherlands
| | - Rob P A Janssen
- Department of Orthopedic Surgery and Trauma, Máxima MC, Eindhoven, the Netherlands.,Department of Biomedical Engineering, Orthopedic Biomechanics, Eindhoven University of Technology, Eindhoven, the Netherlands.,Department of Paramedical Sciences, Chair Value-Based Health Care, Fontys University of Applied Sciences, Eindhoven, the Netherlands
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6
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Allott NEH, Banger MS, McGregor AH. Evaluating the diagnostic pathway for acute ACL injuries in trauma centres: a systematic review. BMC Musculoskelet Disord 2022; 23:649. [PMID: 35799147 PMCID: PMC9261037 DOI: 10.1186/s12891-022-05595-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 06/22/2022] [Indexed: 11/12/2022] Open
Abstract
Objective This review sought to evaluate the literature on the initial assessment and diagnostic pathway for patients with a suspected Anterior Cruciate Ligament (ACL) tear. Methods MEDLINE, EMBASE, and CINAHL were systematically searched for eligible studies, PRISMA guidelines were followed. Studies were included if they used at least one assessment method to assess for ACL injury and participants were assessed at an acute trauma centre within 6-weeks of injury. Article quality was evaluated using the QUADAS-2 checklist. Results A total of 353 studies were assessed for eligibility, 347 were excluded for the following reasons: injuries were not assessed in an acute trauma setting, injuries were not acute, participants had previous ACL injuries or chronic joint deformities affecting the knee, participants were under 18, or participants included animals or cadavers. A total of six studies were included in the review. Common assessment methods included: laxity tests, joint effusion, inability to continue activity, and a history of a ‘pop’ and ‘giving way’ at the time of injury. Diagnostic accuracy varied greatly between the assessment method and the assessing clinician. Gold standard diagnostics were MRI and arthroscopy. A weighted meta-mean calculated the time to reach diagnosis to be 68.60 days [CI 23.94, 113.24]. The mean number of appointments to reach diagnosis varied from 2–5. Delay to surgery or surgical consultation ranged from 61 to 328 days. Conclusion Clinicians in the Emergency Department are not proficient in performing the assessment methods that are used for diagnosis in acute ACL injury. Reliance on specialist assessments or radiological methods inevitably increases the time to reach a diagnosis, which has repercussions on management options. There is an ever-growing demand to improve diagnostic accuracy and efficiency; further exploration into quantitative measures of instability would aid the assessment of peripheral joint assessment.
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Affiliation(s)
- Natasha E H Allott
- Sir Michael Uren Hub, Imperial College London, White City Campus, 86 Wood Lane, London, W12 0BZ, UK.
| | - Matthew S Banger
- Sir Michael Uren Hub, Imperial College London, White City Campus, 86 Wood Lane, London, W12 0BZ, UK
| | - Alison H McGregor
- Sir Michael Uren Hub, Imperial College London, White City Campus, 86 Wood Lane, London, W12 0BZ, UK
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7
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SOBRADO MARCELFARACO, BONADIO MARCELOBATISTA, RIBEIRO GABRIELFERNANDES, GIGLIO PEDRONOGUEIRA, HELITO CAMILOPARTEZANI, DEMANGE MARCOKAWAMURA. LEVER SIGN TEST FOR CHRONIC ACL INJURY: A COMPARISON WITH LACHMAN AND ANTERIOR DRAWER TESTS. ACTA ORTOPEDICA BRASILEIRA 2021; 29:132-136. [PMID: 34290559 PMCID: PMC8266281 DOI: 10.1590/1413-785220212903238345] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/24/2020] [Indexed: 11/22/2022]
Abstract
Objective This study aims to evaluate the sensitivity and specificity of the lever sign test in patients with and without chronic Anterior Cruciate Ligament (ACL) injuries in an outpatient setting and the inter-examiner agreement of surgeons with different levels of experience. Methods 72 consecutive patients with a history of previous knee sprains were included. The Lachman, anterior drawer, and Lever Sign tests were performed for all subjects in a randomized order by three blinded raters with different levels of experience. Sensitivity, specificity, positive predictive value, negative predictive value, and inter-rater agreement were estimated for all tests. Results Among the 72 patients, the prevalence of ACL injuries was 54%. The lever test showed sensitivity of 64.1% (95% CI 0.47-0.78) and specificity of 100% (95% CI 0.87-1.00) for the senior examiner. For the less experienced examiner the sensitivity was 51.8% and the specificity was 93.7%. Positive predictive values (PPV) and negative predictive values (NPV) were 100% and 70.2%, respectively. Conclusion Lever Sign test shows to be a maneuver of easy execution, with 100% specificity and 100% PPV. Moderate agreement between experienced examiners and low agreement among experienced and inexperienced examiners was found. This test may play a role as an auxiliary maneuver. Level of Evidence I, Diagnostic Studies - Investigating a Diagnostic Test.
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8
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Vajapey SP, Miller TL. Effect of native ligament versus graft reconstruction on sensitivity of clinical tests used to diagnose anterior cruciate ligament tears. J Orthop 2021; 26:42-44. [PMID: 34305345 DOI: 10.1016/j.jor.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/08/2021] [Indexed: 10/20/2022] Open
Abstract
Purpose Although there have been multiple clinical studies evaluating the accuracy of physical examination tests used to diagnose anterior cruciate ligament (ACL) injury, there are no data to date evaluating the accuracy of these tests in diagnosing re-injury after prior ACL reconstruction. We compared the sensitivity of three clinical tests - Lachman, anterior drawer, and pivot shift - in diagnosing initial ACL tears versus graft re-tears following a prior ACL reconstruction. Methods Twenty consecutive adult patients who had undergone primary ACL reconstruction and 20 consecutive adult patients who had undergone revision ACL reconstruction by a single surgeon at a tertiary care center from November 2011 to December 2017 were included in this study. Results The sensitivity of the Lachman test was 95.0% in diagnosing ACL tears in patients with native ACL versus 85.0% in patients with prior ACL reconstruction with allograft or autograft. The sensitivity of the anterior drawer test was 80.0% in patients with native ACL compared to 77.8% in patients with prior ACL reconstructions. The sensitivity of the pivot shift test could not be accurately assessed because pain and swelling prevented the physician from performing this test in most patients on their initial presentation to the clinic. Conclusions This study suggests that a clinician may need to have a lower threshold to perform advanced imaging or diagnostic arthroscopic evaluation in a patient with prior ACL reconstruction with a suspected re-injury even if the physical examination tests are not immediately positive.
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Affiliation(s)
- Sravya P Vajapey
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, USA
| | - Timothy L Miller
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, USA
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9
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Clinical tests used to diagnose anterior cruciate ligament tears are less sensitive in obese patients: a retrospective cohort study. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000000943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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10
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Verhagen A, Hancock M. Research Note: Diagnostic test accuracy studies. J Physiother 2021; 67:69-71. [PMID: 33353831 DOI: 10.1016/j.jphys.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022] Open
Affiliation(s)
- Arianne Verhagen
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney, Sydney, Australia.
| | - Mark Hancock
- Faculty of Medicine and Health Science, Macquarie University, Sydney, Australia
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11
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Whittaker JL, Chan M, Pan B, Hassan I, Defreitas T, Hui C, Macedo L, Otto D. Towards improving the identification of anterior cruciate ligament tears in primary point-of-care settings. BMC Musculoskelet Disord 2020; 21:252. [PMID: 32303217 PMCID: PMC7165371 DOI: 10.1186/s12891-020-03237-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/25/2020] [Indexed: 01/13/2023] Open
Abstract
Background Only a small proportion of anterior cruciate ligament (ACL) tears are diagnosed on initial healthcare consultation. Current clinical guidelines do not acknowledge that primary point-of-care practitioners rely more heavily on a clinical history than special clinical tests for diagnosis of an ACL tear. This research will assess the accuracy of combinations of patient-reported variables alone, and in combination with clinician-generated variables to identify an ACL tear as a preliminary step to designing a primary point-of-care clinical decision support tool. Methods Electronic medical records (EMRs) of individuals aged 15–45 years, with ICD-9 codes corresponding to a knee condition, and confirmed (ACL+) or denied (ACL−) first-time ACL tear seen at a University-based Clinic between 2014 and 2016 were eligible for inclusion. Demographics, relevant diagnostic indicators and ACL status based on orthopaedic surgeon assessment and/or MRI reports were manually extracted. Descriptive statistics calculated for all variables by ACL status. Univariate between group comparisons, clinician surveys (n = 17), availability of data and univariable logistic regression (95%CI) were used to select variables for inclusion into multivariable logistic regression models that assessed the odds (95%CI) of an ACL-tear based on patient-reported variables alone (consistent with primary point-of-care practice), or in combination with clinician-generated variables. Model performance was assessed by accuracy, sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios (95%CI). Results Of 1512 potentially relevant EMRs, 725 were included. Participant median age was 26 years (range 15–45), 48% were female and 60% had an ACL tear. A combination of patient-reported (age, sport-related injury, immediate swelling, family history of ACL tear) and clinician-generated (Lachman test result) variables were superior for ACL tear diagnosis [accuracy; 0.95 (90,98), sensitivity; 0.97 (0.88,0.98), specificity; 0.95 (0.82,0.99)] compared to the patient-reported variables alone [accuracy; 84% (77,89), sensitivity; 0.60 (0.44,0.74), specificity; 0.95 (0.89,0.98)]. Conclusions A high proportion of individuals without an ACL tear can be accurately identified by considering patient-reported age, injury setting, immediate swelling and family history of ACL tear. These findings directly inform the development of a clinical decision support tool to facilitate timely and accurate ACL tear diagnosis in primary care settings.
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Affiliation(s)
- Jackie L Whittaker
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, 2177 Westbrook Mall, Vancouver, V6T 1Z3, Canada. .,Arthritis Research Canada, Richmond, Canada. .,Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada.
| | - Michelle Chan
- Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Canada
| | - Bo Pan
- EPICORE Centre & Alberta SPOR Support Unit, Consultation & Research Services, University of Alberta, Edmonton, Canada
| | - Imran Hassan
- EPICORE Centre & Alberta SPOR Support Unit, Consultation & Research Services, University of Alberta, Edmonton, Canada
| | - Terry Defreitas
- Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Canada.,Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Catherine Hui
- Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Canada.,Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Luciana Macedo
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - David Otto
- Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Canada.,Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
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12
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Molenaars RJ, van den Bekerom MPJ, Nazal MR, Eygendaal D, Oh LS. Clinical Value of an Acute Popping Sensation in Throwing Athletes With Medial Elbow Pain for Ulnar Collateral Ligament Injury. Orthop J Sports Med 2020; 8:2325967119893275. [PMID: 31984213 PMCID: PMC6961145 DOI: 10.1177/2325967119893275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 09/25/2019] [Indexed: 12/03/2022] Open
Abstract
Background: Throwing athletes sustaining an ulnar collateral ligament (UCL) injury may
recall a popping sensation originating from the medial elbow at the time of
injury. There are no studies available that inform clinicians how to utilize
this salient anamnestic information and what amount of diagnostic weight to
afford to it. Purpose: To assess the diagnostic value of a popping sensation for significant UCL
injury in throwing athletes who sustained an injury causing medial elbow
pain. Study Design: Cohort study (prognosis); Level of evidence, 3. Methods: A total of 207 consecutive patients with throwing-related medial elbow pain
were evaluated for UCL injury by the senior author between 2011 and 2016.
The presence or absence of a popping sensation was routinely reported by the
senior author. Magnetic resonance imaging was evaluated for UCL injury
severity and classified into intact, edema/low-grade partial-, high-grade
partial-, and full-thickness tears. Results: The overall frequency of a pop was 26%. The proportion of patients who
reported a pop significantly increased with UCL tear severity
(P < .001), from 13% in patients with low-grade UCL
injuries to 26% in patients with high-grade partial-thickness tears and 51%
in patients with full-thickness tears. The positive likelihood ratio,
negative likelihood ratio, and odds ratio of a popping sensation for
significant UCL injury were 3.2, 0.7, and 4.4 (P <
.001), respectively (P < .001). A pop was not associated
with either distal or proximal UCL tears (P ≥ .999). Conclusion: A popping sensation at the time of injury in throwing athletes with medial
elbow pain was associated with UCL injury severity. When a throwing athlete
reports a pop, this should moderately increase a clinician’s suspicion for a
significant UCL injury. Conversely, absence of a pop should not
substantially decrease suspicion for significant UCL injury. The findings of
this study allow for the clinical interpretation of the salient anamnestic
finding of a pop at the time of injury, which can be used for diagnostic
purposes as well as patient counseling. This study provides reference
foundation for future studies of predictive and diagnostic factors for UCL
injury in throwing athletes.
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Affiliation(s)
- Rik J Molenaars
- Sports Medicine Center, Harvard Medical School at Massachusetts General Hospital, Boston, Massachusetts, USA.,Amsterdam University Medical Centers, Department of Orthopaedic Surgery, University of Amsterdam, Amsterdam, the Netherlands
| | - Michel P J van den Bekerom
- Shoulder and Elbow Unit, Joint Research, Department of Orthopedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Mark R Nazal
- Amsterdam University Medical Centers, Department of Orthopaedic Surgery, University of Amsterdam, Amsterdam, the Netherlands
| | - Denise Eygendaal
- Amsterdam University Medical Centers, Department of Orthopaedic Surgery, University of Amsterdam, Amsterdam, the Netherlands.,Department of Orthopaedic Surgery, Amphia Hospital, Breda, the Netherlands
| | - Luke S Oh
- Amsterdam University Medical Centers, Department of Orthopaedic Surgery, University of Amsterdam, Amsterdam, the Netherlands
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13
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Noh JH, Nam WD, Roh YH. Anterior tibial displacement on preoperative stress radiography of ACL-injured knee depending on knee flexion angle. Knee Surg Relat Res 2019; 31:14. [PMID: 32660620 PMCID: PMC7219608 DOI: 10.1186/s43019-019-0014-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/22/2019] [Indexed: 12/31/2022] Open
Abstract
Purpose To compare side-to-side difference (SSD) of anterior tibial translation in instrumented stress radiography for each series of anterior cruciate ligament (ACL)-injured subjects according to knee flexion angle. Methods Forty subjects who were suspected of having significant ACL injury by manual Lachman test and MRI were recruited for this prospective study. These subjects took stress radiographs for both knees with corresponding knee flexion of 10° (series M1) and 30° (series M2) using Telos stress device. Mean SSDs of M1 and M2 were compared. Sensitivities of M1 and M2 were assessed using the SSD ≥ 3 mm or ≥ 5 mm as a cutoff value. Results Mean SSDs in series M1 and M2 were 4.22 ± 3.72 mm and 3.25 ± 3.30 mm, respectively (p < 0.001). When 3 mm of SSD was used as a cutoff value, sensitivities of series M1 and M2 were 47.5% (19/40) and 32.5% (13/40), respectively (p = 0.171). When 5 mm of SSD was used as a cutoff value, sensitivities of series M1 and M2 were 45.0% (18/40) and 22.5% (9/40), respectively (p = 0.033). Conclusions Anterior tibial translation on stress radiographs using a Telos device is more prominent when knee flexion angle is 10° compared to that when knee flexion angle is 30°. However, stress radiography using Telos device, either at 10° or 30° of knee flexion, might not be suitable to make decision on surgical treatment due to relatively low sensitivities.
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Affiliation(s)
- Jung Ho Noh
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kangwon National University, 1 Kangwondaehak-gil, Chuncheon-si, Gangwon-do, 24341, South Korea.
| | - Woo Dong Nam
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kangwon National University, 1 Kangwondaehak-gil, Chuncheon-si, Gangwon-do, 24341, South Korea
| | - Young Hak Roh
- Department of Orthopaedic Surgery, Ewha Womans University School of Medicine, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, South Korea
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14
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Abstract
Hip and knee injuries are a common presenting concern for patients to a primary care office. This pathology represents a large differential and it can often be a diagnostic challenge for providers to determine the etiology of a patient's symptoms. This article discusses several of the most common causes for hip and knee pain while providing an evidence based review of physical examination maneuvers, imaging studies and treatment modalities to assist a primary care provider when encountering active patients with underlying hip or knee pain.
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Affiliation(s)
- Stephen M Carek
- Department of Family Medicine, University of South Carolina, School of Medicine-Greenville, Center for Family Medicine - Greenville, 877 West Faris Road, Greenville, SC 29605, USA..
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15
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Swart NM, van Oudenaarde K, Bierma-Zeinstra SMA, Bloem JL, Bindels PJE, Algra PR, Reijnierse M, Luijsterburg PAJ. Predicting no return to sports after three months in patients with traumatic knee complaints in general practice by combining patient characteristics, trauma characteristics and knee complaints. Eur J Gen Pract 2019; 25:205-213. [PMID: 31431084 PMCID: PMC6853237 DOI: 10.1080/13814788.2019.1646241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: It remains unclear to what extent patients with traumatic knee complaints aged 18–45 years seen in general practice experience difficulties with return to sports. Objectives: This study aims to determine the proportion of patients with a knee trauma that return to sports at six weeks and three months follow-up. Also examined were associations between no return to sports and baseline patient/trauma characteristics, knee complaints and MR (magnetic resonance) findings, as well as the additive value of MR findings. Methods: Included were patients with traumatic knee complaints participating in a randomized controlled trial assessing the cost-effectiveness of an MR scan in general practice. Patients were classified as ‘no return to sports’ or ‘return to sports’ (sports on pre-injury or adapted level). Potential baseline predictors for no return to sports were assessed using logistic regression analyses. The area under the curves (AUC) was compared. Results: At six weeks and three months follow-up, 147 (59%) and 175 (74%) patients, respectively, reported return to sports. Combining patient characteristics, trauma characteristics and knee complaints predicted no return to sports with an AUC of 0.86 (95%CI: 0.81–0.90) at six weeks and of 0.82 (95%CI: 0.76–0.88) at three months follow-up. After adding MR findings, the AUC was 0.79 (95%CI: 0.71–0.87) at six weeks and 0.79 (95%CI: 0.70–0.88) at three months follow-up. Conclusion: Three out of four patients with a knee trauma in general practice reported return to sports at three months follow-up. A combination of patient/trauma characteristics and knee complaints predicted no return to sports, whereas MR findings had no additive value. Trial registration: Dutch trial registration: registration number: NTR3689. registration date: 7 November 2012.
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Affiliation(s)
- Nynke M Swart
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Kim van Oudenaarde
- Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sita M A Bierma-Zeinstra
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Orthopaedics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johan L Bloem
- Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Patrick J E Bindels
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Paul R Algra
- Department of Radiology, Northwest Clinics, location Alkmaar, Alkmaar, The Netherlands
| | - Monique Reijnierse
- Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Pim A J Luijsterburg
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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16
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Vega JF, Strnad GJ, Bena J, Spindler KP. Predicting the Need for Surgical Intervention Prior to First Encounter for Individuals With Knee Complaints: A Novel Approach. Orthop J Sports Med 2019; 7:2325967119859485. [PMID: 31384618 PMCID: PMC6659191 DOI: 10.1177/2325967119859485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Orthopaedic complaints, particularly those relating to the knee, are some of the most common conditions that bring patients to the hospital. Many patients bypass their primary care physician to seek the care of an orthopaedic surgeon without referral, leaving the surgeon to manage an increasingly large number of patients, many of whom will never require surgery. Purpose To develop a brief questionnaire that can be administered via phone/web at the time of appointment request to predict an individual patient's probability of requiring surgical intervention. Study Design Case-control study; Level of evidence, 3. Methods All patients (N = 1307) seeking an appointment for a new knee-related complaint completed a branching-logic questionnaire. A retrospective chart review was conducted following the conclusion of each patient's episode of care to determine whether surgery was recommended. Logistic regression models were used to predict the risk of surgery based on triage question responses, basic demographics (age, sex), and laterality (unilateral vs bilateral). The ability of the models to discriminate between those who did and did not receive a surgical recommendation was measured with a concordance index. Results The model provided a high level of discrimination between surgical and nonsurgical cases (concordance index, 0.69). Recent injury with inability to walk and no recent injury with no pain were both associated with an increased probability of receiving a recommendation of surgical intervention as compared with patients who reported pain without recent injury (odds ratio [OR]: 3.51 [P < .001] and 2.78 [P = .008], respectively). A unilateral complaint was associated with needing surgical intervention (OR, 4.52 [P < .001]). Age had a significant nonlinear relationship with odds of needing of surgery, with middle-aged patients (range, 20-50 years) having the greatest odds. Conclusion The current model, which utilizes demographic questions and portions of a routine history alone, was able to accurately identify individuals who are most likely (up to 65% probability) and least likely (<5% probability) to need knee surgery. This model can quickly and easily conduct triage at the time of appointment request to ensure that patients with the highest likelihood of receiving a recommendation for surgical intervention are seen by surgical providers, while those who are unlikely to receive such a recommendation can be seen by nonsurgical providers.
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Affiliation(s)
- José F Vega
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA.,Cleveland Clinic Orthopaedics Department, Cleveland, Ohio, USA
| | | | - James Bena
- Cleveland Clinic Quantitative Health Sciences, Cleveland, Ohio, USA
| | - Kurt P Spindler
- Cleveland Clinic Orthopaedic Sports Health, Cleveland, Ohio, USA
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17
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Mautner K, Sussman WI, Nanos K, Blazuk J, Brigham C, Sarros E. Validity of Indirect Ultrasound Findings in Acute Anterior Cruciate Ligament Ruptures. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:1685-1692. [PMID: 30480325 DOI: 10.1002/jum.14853] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/02/2018] [Accepted: 09/16/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Ultrasound (US) is increasingly being used as an extension of the physical examination on the sidelines, in training rooms, and in clinics. Anterior cruciate ligament (ACL) injury in sport is common, but the literature on US findings after acute ACL rupture is limited. Three indirect US findings of ACL rupture have been described, and this study assessed the validity of these indirect signs. METHODS Patients with an acute knee injury (<6 weeks) underwent US examinations to determine whether there was evidence of a femoral notch sign, posterior cruciate ligament wave sign, or capsular protrusion sign. Ultrasound findings were compared to magnetic resonance imaging. RESULTS Sixty-nine patients were included (53 with ACL tears and 16 control patients). The posterior cruciate ligament sign had the highest sensitivity (84.9%), and the notch sign had the highest specificity (93.8%). If 2 or 3 of the signs were positive, the sensitivity was 86.8%, and the specificity was 87.5%. CONCLUSIONS A US examination is an easy-to-perform and noninvasive test, and the 3 indirect signs of an acute ACL tear had high positive predictive values ranging from 91.8% to 96.8%.
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Affiliation(s)
- Ken Mautner
- Departments of Physical Medicine and Rehabilitation and Orthopedics, Emory University, Atlanta, Georgia, USA
- Departments of Orthopedics, Emory University, Atlanta, Georgia, USA
| | - Walter I Sussman
- Department of Physical Medicine and Rehabilitation, Tufts University, Boston, Massachusetts, USA
- Orthopedic Care Physician Network, North Easton, Massachusetts, USA
| | - Katie Nanos
- High-Performance Sports Medicine, Toronto, Ontario, Canada
| | - Joe Blazuk
- Orthopedic Clinic Association, Phoenix, Arizona, USA
| | | | - Emily Sarros
- Departments of Orthopedics, Emory University, Atlanta, Georgia, USA
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18
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Post-traumatic knee MRI findings and associations with patient, trauma, and clinical characteristics: a subgroup analysis in primary care in the Netherlands. Br J Gen Pract 2018; 67:e851-e858. [PMID: 29158244 DOI: 10.3399/bjgp17x693653] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 07/06/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The added value of magnetic resonance imaging (MRI) in primary care is still being debated. A high diagnostic yield can be expected in young and active patients with post-traumatic knee complaints. AIM To determine the frequency of MRI abnormalities in young and active patients (aged 18-45 years) and the associations with patient, trauma, and clinical characteristics. DESIGN AND SETTING A subgroup analysis of 174 patients, aged 18-45 years with knee trauma of <6 months, allocated to MRI in a randomised controlled trial on the yield of MRI in primary care. Patients were recruited by 150 GPs in the Netherlands from October 2012 to November 2015. METHOD Associations were expressed using mean differences, odds ratio (OR) and predictive values. RESULTS Sixty-seven out of 174 patients (39%) had a positive MRI finding, predominantly anterior cruciate ligament (ACL) ruptures (22%) and/or traumatic meniscal tears (15%). Patients with a pre-existing musculoskeletal comorbidity had a two-fold lower prevalence of positive MRI findings (21%), OR 3.0 (95% confidence interval [CI] = 1.3 to 7.0). A 'sports related trauma' showed the highest OR of 4.6 (95% CI = 2.2 to 9.3) for a positive MRI finding. Clinical scores were statistically, significantly worse in patients with positive MRI findings, with mean differences ranging from 10 to 20%. Furthermore, increasing duration of complaints was correlated with decreasing prevalence rates of positive MRI findings. Overall, a popping sound and direct swelling showed the highest positive predictive value of 65% for the presence of positive MRI findings. CONCLUSION The results from this study enable a preselection of patients to increase the diagnostic yield of MRI in primary care.
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19
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Clinical diagnosis of partial or complete anterior cruciate ligament tears using patients' history elements and physical examination tests. PLoS One 2018; 13:e0198797. [PMID: 29894492 PMCID: PMC5997333 DOI: 10.1371/journal.pone.0198797] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 05/25/2018] [Indexed: 01/13/2023] Open
Abstract
Objective To assess the diagnostic validity of clusters combining history elements and physical examination tests to diagnose partial or complete anterior cruciate ligament (ACL) tears. Design Prospective diagnostic study. Settings Orthopaedic clinics (n = 2), family medicine clinics (n = 2) and community-dwelling. Participants Consecutive patients with a knee complaint (n = 279) and consulting one of the participating orthopaedic surgeons (n = 3) or sport medicine physicians (n = 2). Interventions Not applicable. Main outcome measures History elements and physical examination tests performed independently were compared to the reference standard: an expert physicians’ composite diagnosis including history elements, physical tests and confirmatory magnetic resonance imaging. Penalized logistic regression (LASSO) was used to identify history elements and physical examination tests associated with the diagnosis of ACL tear and recursive partitioning was used to develop diagnostic clusters. Diagnostic accuracy measures including sensitivity (Se), specificity (Sp), predictive values and positive and negative likelihood ratios (LR+/-) with associated 95% confidence intervals (CI) were calculated. Results Forty-three individuals received a diagnosis of partial or complete ACL tear (15.4% of total cohort). The Lachman test alone was able to diagnose partial or complete ACL tears (LR+: 38.4; 95%CI: 16.0–92.5). Combining a history of trauma during a pivot with a “popping” sensation also reached a high diagnostic validity for partial or complete tears (LR+: 9.8; 95%CI: 5.6–17.3). Combining a history of trauma during a pivot, immediate effusion after trauma and a positive Lachman test was able to identify individuals with a complete ACL tear (LR+: 17.5; 95%CI: 9.8–31.5). Finally, combining a negative history of pivot or a negative popping sensation during trauma with a negative Lachman or pivot shift test was able to exclude both partial or complete ACL tears (LR-: 0.08; 95%CI: 0.03–0.24). Conclusion Diagnostic clusters combining history elements and physical examination tests can support the differential diagnosis of ACL tears compared to various knee disorders.
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20
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Décary S, Fallaha M, Pelletier B, Frémont P, Martel-Pelletier J, Pelletier JP, Feldman DE, Sylvestre MP, Vendittoli PA, Desmeules F. Diagnostic validity and triage concordance of a physiotherapist compared to physicians' diagnoses for common knee disorders. BMC Musculoskelet Disord 2017; 18:445. [PMID: 29137611 PMCID: PMC5686957 DOI: 10.1186/s12891-017-1799-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 11/01/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergence of more autonomous roles for physiotherapists warrants more evidence regarding their diagnostic capabilities. Therefore, we aimed to evaluate diagnostic and surgical triage concordance between a physiotherapist and expert physicians and to assess the diagnostic validity of the physiotherapist's musculoskeletal examination (ME) without imaging. METHODS This is a prospective diagnostic study where 179 consecutive participants consulting for any knee complaint were independently diagnosed and triaged by two evaluators: a physiotherapist and one expert physician (orthopaedic surgeons or sport medicine physicians). The physiotherapist completed only a ME, while the physicians also had access to imaging to make their diagnosis. Raw agreement proportions and Cohen's kappa (k) were calculated to assess inter-rater agreement. Sensitivity (Se) and specificity (Sp), as well as positive and negative likelihood ratios (LR+/-) were calculated to assess the validity of the ME compared to the physicians' composite diagnosis. RESULTS Primary knee diagnoses included anterior cruciate ligament injury (n = 8), meniscal injury (n = 36), patellofemoral pain (n = 45) and osteoarthritis (n = 79). Diagnostic inter-rater agreement between the physiotherapist and physicians was high (k = 0.89; 95% CI:0.83-0.94). Inter-rater agreement for triage recommendations of surgical candidates was good (k = 0.73; 95% CI:0.60-0.86). Se and Sp of the physiotherapist's ME ranged from 82.0 to 100.0% and 96.0 to 100.0% respectively and LR+/- ranged from 23.2 to 30.5 and from 0.03 to 0.09 respectively. CONCLUSIONS There was high diagnostic agreement and good triage concordance between the physiotherapist and physicians. The ME without imaging may be sufficient to diagnose or exclude common knee disorders for a large proportion of patients. Replication in a larger study will be required as well as further assessment of innovative multidisciplinary care trajectories to improve care of patients with common musculoskeletal disorders.
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Affiliation(s)
- S. Décary
- 0000 0001 2292 3357grid.14848.31School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, QC Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal, Montreal, QC Canada
| | - M. Fallaha
- 0000 0001 2292 3357grid.14848.31Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, QC, Canada. Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal, Montreal, QC Canada
| | - B. Pelletier
- 0000 0001 2292 3357grid.14848.31Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, QC, Canada. Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal, Montreal, QC Canada
| | - P. Frémont
- 0000 0004 1936 8390grid.23856.3aDepartment of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, QC Canada
| | - J. Martel-Pelletier
- 0000 0001 0743 2111grid.410559.cOsteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, QC Canada
| | - J.-P. Pelletier
- 0000 0001 0743 2111grid.410559.cOsteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, QC Canada
| | - D. E. Feldman
- 0000 0001 2292 3357grid.14848.31School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, QC Canada
| | - M.-P. Sylvestre
- 0000 0001 2292 3357grid.14848.31Department of Social Preventive Medicine, School of Public Health, Université de Montréal, Montreal, QC Canada
| | - P.-A. Vendittoli
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal, Montreal, QC Canada
- 0000 0001 2292 3357grid.14848.31Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, QC, Canada. Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal, Montreal, QC Canada
| | - F. Desmeules
- 0000 0001 2292 3357grid.14848.31School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, QC Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal, Montreal, QC Canada
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21
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Décary S, Fallaha M, Frémont P, Martel-Pelletier J, Pelletier JP, Feldman DE, Sylvestre MP, Vendittoli PA, Desmeules F. Diagnostic Validity of Combining History Elements and Physical Examination Tests for Traumatic and Degenerative Symptomatic Meniscal Tears. PM R 2017; 10:472-482. [PMID: 29111463 DOI: 10.1016/j.pmrj.2017.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 09/19/2017] [Accepted: 10/21/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND The current approach to the clinical diagnosis of traumatic and degenerative symptomatic meniscal tears (SMTs) proposes combining history elements and physical examination tests without systematic prescription of imaging investigations, yet the evidence to support this diagnostic approach is scarce. OBJECTIVE To assess the validity of diagnostic clusters combining history elements and physical examination tests to diagnose or exclude traumatic and degenerative SMT compared with other knee disorders. DESIGN Prospective diagnostic accuracy study. SETTINGS Patients were recruited from 2 orthopedic clinics, 2 family medicine clinics, and from a university community. PATIENTS A total of 279 consecutive patients who underwent consultation for a new knee complaint. METHODS Each patient was assessed independently by 2 evaluators. History elements and standardized physical examination tests performed by a physiotherapist were compared with the reference standard: an expert physicians' composite diagnosis including a clinical examination and confirmatory magnetic resonance imaging. Participating expert physicians were orthopedic surgeons (n = 3) or sport medicine physicians (n = 2). Penalized logistic regression (least absolute shrinkage and selection operator) was used to identify history elements and physical examination tests associated with the diagnosis of SMT and recursive partitioning was used to develop diagnostic clusters. MAIN OUTCOME MEASURES Diagnostic accuracy measures were calculated including sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios (LR+/-) with associated 95% confidence intervals (CIs). RESULTS Eighty patients had a diagnosis of SMT (28.7%), including 35 traumatic tears and 45 degenerative tears. The combination a history of trauma during a pivot, medial knee pain location, and a positive medial joint line tenderness test was able to diagnose (LR+ = 8.9; 95% CI 6.1-13.1) or exclude (LR- = 0.10; 95% CI 0.03-0.28) a traumatic SMT. Combining a history of progressive onset of pain, medial knee pain location, pain while pivoting, absence of valgus or varus knee misalignment, or full passive knee flexion was able to moderately diagnose (LR+ = 6.4; 95% CI 4.0-10.4) or exclude (LR- = 0.10; 95% CI 0.03-0.31) a degenerative SMT. Internal validation estimates were slightly lower for all clusters but demonstrated positive LR superior to 5 and negative LR inferior to 0.2 indicating moderate shift in posttest probability. CONCLUSION Diagnostic clusters combining history elements and physical examination tests can support the differential diagnosis of SMT. These results represent the initial derivation of the clusters and external validation is mandatory. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Simon Décary
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec; and Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec; and Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
- Osteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec; and Department of Social Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec; and Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
| | - Michel Fallaha
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec; and Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec; and Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
- Osteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec; and Department of Social Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec; and Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
| | - Pierre Frémont
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec; and Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec; and Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
- Osteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec; and Department of Social Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec; and Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
| | - Johanne Martel-Pelletier
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec; and Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec; and Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
- Osteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec; and Department of Social Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec; and Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
| | - Jean-Pierre Pelletier
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec; and Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec; and Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
- Osteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec; and Department of Social Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec; and Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
| | - Debbie E Feldman
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec; and Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec; and Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
- Osteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec; and Department of Social Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec; and Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
| | - Marie-Pierre Sylvestre
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec; and Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec; and Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
- Osteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec; and Department of Social Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec; and Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
| | - Pascal-André Vendittoli
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec; and Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec; and Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
- Osteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec; and Department of Social Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec; and Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
| | - François Desmeules
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec; and Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec; and Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
- Osteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec; and Department of Social Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec; and Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Montreal, Quebec, Canada
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Décary S, Ouellet P, Vendittoli PA, Roy JS, Desmeules F. Diagnostic validity of physical examination tests for common knee disorders: An overview of systematic reviews and meta-analysis. Phys Ther Sport 2016; 23:143-155. [PMID: 27693100 DOI: 10.1016/j.ptsp.2016.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 08/02/2016] [Accepted: 08/04/2016] [Indexed: 12/18/2022]
Abstract
INTRODUCTION More evidence on diagnostic validity of physical examination tests for knee disorders is needed to lower frequently used and costly imaging tests. OBJECTIVE To conduct a systematic review of systematic reviews (SR) and meta-analyses (MA) evaluating the diagnostic validity of physical examination tests for knee disorders. METHODS A structured literature search was conducted in five databases until January 2016. Methodological quality was assessed using the AMSTAR. RESULTS Seventeen reviews were included with mean AMSTAR score of 5.5 ± 2.3. Based on six SR, only the Lachman test for ACL injuries is diagnostically valid when individually performed (Likelihood ratio (LR+):10.2, LR-:0.2). Based on two SR, the Ottawa Knee Rule is a valid screening tool for knee fractures (LR-:0.05). Based on one SR, the EULAR criteria had a post-test probability of 99% for the diagnosis of knee osteoarthritis. Based on two SR, a complete physical examination performed by a trained health provider was found to be diagnostically valid for ACL, PCL and meniscal injuries as well as for cartilage lesions. CONCLUSION When individually performed, common physical tests are rarely able to rule in or rule out a specific knee disorder, except the Lachman for ACL injuries. There is low-quality evidence concerning the validity of combining history elements and physical tests.
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Affiliation(s)
- Simon Décary
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada; Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montreal, Quebec, Canada.
| | - Philippe Ouellet
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada; Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montreal, Quebec, Canada.
| | - Pascal-André Vendittoli
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montreal, Quebec, Canada; Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada.
| | - Jean-Sébastien Roy
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada; Centers for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec City, Canada.
| | - François Desmeules
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada; Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montreal, Quebec, Canada.
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Efficacy of knee joint aspiration in patients with acute ACL injury in the emergency department. Injury 2016; 47:1744-9. [PMID: 27262773 DOI: 10.1016/j.injury.2016.05.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/09/2016] [Accepted: 05/16/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the influence of joint aspiration on the sensitivity of physical examination for diagnosing acute anterior cruciate ligament (ACL) lesion in the second outpatient-department (OPD) follow-up referred from emergency department (ED). METHODS This retrospective study included sixty patients underwent ACL reconstruction with initial visit at ED. They were divided into two groups based on the presence or absence of joint aspiration at ED. All participants were referred to second OPD follow-up within 7-14days after the injury. Clinical manifestation (including visual analogue scale (VAS) for pain, range of motion (ROM), and severity of knee effusion) and physical examination (Lachman test and pivot shift test) were checked in ED and the second OPD follow-up. RESULTS The group of patients with joint aspiration (G1) showed substantial decreases in mean values of VAS for pain (p=0.005), ROM (p=0.001), and effusion level (p<0.001), even higher VAS and effusion level and lower ROM at the initial visit of ED than the other group (G2). The sensitivity of positive Lachman and pivot shift test was significantly (p<0.05) increased following knee joint aspiration. Positive Lachman test was recorded at 76.5% in the second follow-up in G1, which was significantly (p=0.047) higher than that (47.6%) in G2. The percentage of positive pivot shift test was recorded at 76.5% in the second follow-up in G1, which as significantly (p<0.001) higher than that (31.0%) in G2. CONCLUSIONS Knee joint aspiration in acute ACL injury with suspected hemarthrosis could be considered as a diagnostic procedure. Joint aspiration in early medical attendance might be able to lower pain scores or raise the sensitivity of physical examination for diagnosing acute ACL injury at follow up visit in orthopedic outpatient department. LEVEL OF EVIDENCE Retrospective cohort study III.
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Parwaiz H, Teo AQA, Servant C. Anterior cruciate ligament injury: A persistently difficult diagnosis. Knee 2016; 23:116-20. [PMID: 26552783 DOI: 10.1016/j.knee.2015.09.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 09/22/2015] [Accepted: 09/25/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Historically anterior cruciate ligament (ACL) injuries have been diagnosed poorly. A paper published in Injury in 1996 showed that less than 10% of patients with an ACL injury had the diagnosis made by the first physician to see them and that the average delay from first presentation to diagnosis was 21 months. The aim of our study was to investigate whether an improvement has been made over the last two decades in diagnosing ACL injuries. METHODS We identified 160 patients who had an ACL reconstruction performed by a single surgeon between October 2004 and December 2011 and for whom a complete data set was available. Data was extracted retrospectively from the hospital notes and a dedicated patient database. We performed a sub-group analysis comparing patients seen prior to the introduction of an acute knee injury clinic in April 2007 and patients seen after the introduction of the clinic. RESULTS 75.1% (120/160) of patients presented first to an emergency department (ED) or to their general practitioner (GP), but only 14.4% (23/160) were diagnosed on initial presentation. The median number of healthcare professionals a patient saw prior to a diagnosis of ACL injury was 3. The median delay from injury to presentation was 0 weeks (range 0-885), injury to diagnosis 13 weeks (0-926), presentation to diagnosis 10 weeks (0-924), presentation to a specialist knee clinic 24 weeks (0-1006), and specialist knee clinic to surgery 13 weeks (0-102). The median total time from injury to surgery was 42 weeks (0-1047). Following the implementation of an acute knee injury clinic in 2007, the median delay from presentation to surgery dropped from 59 weeks to 36 weeks (p = 0.050) and there was a significant decrease in the median delay from specialist knee clinic to surgery from 23 to 11 weeks (p=0.002). CONCLUSION Over the past two decades there appears to have been little improvement in the early diagnosis of ACL injuries, with only 14.4% of patients being diagnosed correctly at initial presentation. We recommend further education of emergency and primary care clinicians in the diagnosis of ACL injuries, emphasising the importance of the typical history of an ACL injury. The implementation of an acute knee injury clinic may help minimise delays to surgery, which should result in better patient outcomes.
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Affiliation(s)
- Hammad Parwaiz
- Ipswich Hospital NHS Trust, Heath Rd, Ipswich, Suffolk IP4 5PD, United Kingdom.
| | - Alex Q A Teo
- Ipswich Hospital NHS Trust, Heath Rd, Ipswich, Suffolk IP4 5PD, United Kingdom
| | - Christopher Servant
- Ipswich Hospital NHS Trust, Heath Rd, Ipswich, Suffolk IP4 5PD, United Kingdom
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Diagnostic accuracy of physical examination for anterior knee instability: a systematic review. Knee Surg Sports Traumatol Arthrosc 2015; 23:2805-13. [PMID: 25763847 DOI: 10.1007/s00167-015-3563-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 03/02/2015] [Indexed: 01/15/2023]
Abstract
PURPOSE Determining diagnostic accuracy of Lachman, pivot shift and anterior drawer tests versus gold standard diagnosis (magnetic resonance imaging or arthroscopy) for anterior cruciate ligament (ACL) insufficiency cases. Secondarily, evaluating effects of: chronicity, partial rupture, awake versus anaesthetized evaluation. METHODS Searching MEDLINE, EMBASE and PubMed identified studies on diagnostic accuracy for ACL insufficiency. Studies identification and data extraction were performed in duplicate. Quality assessment used QUADAS tool, and statistical analyses were completed for pooled sensitivity and specificity. RESULTS Eight studies were included. Given insufficient data, pooled analysis was only possible for sensitivity on Lachman and pivot shift test. During awake evaluation, sensitivity for the Lachman test was 89 % (95 % CI 0.76, 0.98) for all rupture types, 96 % (95 % CI 0.90, 1.00) for complete ruptures and 68 % (95 % CI 0.25, 0.98) for partial ruptures. For pivot shift in awake evaluation, results were 79 % (95 % CI 0.63, 0.91) for all rupture types, 86 % (95 % CI 0.68, 0.99) for complete ruptures and 67 % (95 % CI 0.47, 0.83) for partial ruptures. CONCLUSION Decreased sensitivity of Lachman and pivot shift tests for partial rupture cases and for awake patients raised suspicions regarding the accuracy of these tests for diagnosis of ACL insufficiency. This may lead to further research aiming to improve the understanding of the true accuracy of these physical diagnostic tests and increase the reliability of clinical investigation for this pathology. LEVEL OF EVIDENCE IV.
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Luijsterburg PAJ, Wagemakers HPA, Kastelein M, Verhaar JAN, Koster IM, Oei EHG, Koes BW, Bierma-Zeinstra SMA. Knee instability in patients with traumatic knee disorders: a cohort study in primary care. Fam Pract 2015; 32:367-73. [PMID: 25902913 DOI: 10.1093/fampra/cmv023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There is a lack of knowledge about the course of knee instability in patients with traumatic knee disorders. OBJECTIVE The aim of the study was to determine the course of traumatic knee instability during 1-year follow-up and to observe the treatment of knee instability by GPs. METHODS Patients (n = 134) aged 18-65 years with traumatic knee disorders who consulted their GP within 5 weeks after trauma were enrolled in a prospective cohort study. Data were collected at baseline and at 3, 6 and 12 months follow-up. Magnetic resonance imaging (MRI) and physical examination of the knee were performed at baseline and at 1-year follow-up. RESULTS At baseline, 28% of the 134 patients had no knee instability, 17% reported knee instability (according Lysholm score), 31% tested positive on knee instability (according Lachman test) and 24% both self-reported and tested positive on instability of the knee. At baseline and at 1-year follow-up, no clear differences between MRI findings, treatment and course of the defined groups of knee instability were found. At 1-year follow-up, patients with both self-reported and tested positive seemed to have worse outcomes. CONCLUSION During 1-year follow-up, it was unclear if there were differences regarding course, treatment and MRI findings of the knee between no instability and the three defined knee instability groups. Statistical power was lacking in the comparisons made and therefore studies with more patients are needed.
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Affiliation(s)
| | | | | | - Jan A N Verhaar
- Department of Orthopaedics, Erasmus MC, University Medical Center, Rotterdam
| | - Ingrid M Koster
- Department of Radiology, Albert Schweitzer Hospital, Dordrecht and
| | - Edwin H G Oei
- Department of Radiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Sita M A Bierma-Zeinstra
- Department of General Practice and Department of Orthopaedics, Erasmus MC, University Medical Center, Rotterdam
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Geraets SEW, Meuffels DE, van Meer BL, Breedveldt Boer HP, Bierma-Zeinstra SMA, Reijman M. Diagnostic value of medical history and physical examination of anterior cruciate ligament injury: comparison between primary care physician and orthopaedic surgeon. Knee Surg Sports Traumatol Arthrosc 2015; 23:968-74. [PMID: 25964958 DOI: 10.1007/s00167-013-2769-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Well-designed validity studies on the clinical diagnosis of anterior cruciate ligament (ACL) injury are scarce. Our purpose is to assess the diagnostic value of ACL-specific medical history assessment and physical examination between primary and secondary care medical specialists. METHODS Medical history assessment and physical examination were performed by both an orthopaedic surgeon and a primary care physician, both blinded to all clinical information, in a secondary care population. A knee arthroscopy was used as reference standard. A total of 60 participants were divided into an index group with an arthroscopically proven complete ACL rupture and a control group with an arthroscopically proven intact ACL. RESULTS The orthopaedic surgeon recognized 94 % of the participants with an ACL rupture through a positive medical history combined with a positive physical examination; of the participants with an intact ACL, 16 % were misclassified by the orthopaedic surgeon. The primary care physician recognized 62 % of the participants with an ACL rupture and misclassified 23 % of the participants with an intact ACL. Physical examination appeared to have no additional value for the primary care physician. CONCLUSIONS Combined medical history and physical examination have strong diagnostic value in ACL rupture diagnostics performed by an orthopaedic surgeon, whereas for the primary care physician, only medical history appeared to be of value. For current practice, this could mean that only orthopaedic surgeons can perform an ACL physical examination with accuracy. LEVEL OF EVIDENCE III.
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Wylie JD, Crim JR, Working ZM, Schmidt RL, Burks RT. Physician provider type influences utilization and diagnostic utility of magnetic resonance imaging of the knee. J Bone Joint Surg Am 2015; 97:56-62. [PMID: 25568395 DOI: 10.2106/jbjs.n.00065] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Magnetic resonance imaging of the knee is expensive and is neither needed nor useful for all patients presenting with knee pain. Our objective was to determine the completeness of evaluation prior to ordering magnetic resonance imaging of the knee correlated to the ordering providers' postgraduate medical training and the rate of positive findings on the subsequent magnetic resonance imaging. METHODS Six hundred consecutive knee magnetic resonance images were reviewed, including 200 consecutive knee magnetic resonance imaging examinations from each of three provider types: orthopaedic surgeons, non-surgical physicians with sports medicine training, and primary care providers. Positive findings on magnetic resonance imaging were recorded as well as a history of present illness, a physical examination, and radiographs made prior to ordering magnetic resonance imaging of the knee. Patient and injury factors were recorded. Differences in patient factors, evaluation before magnetic resonance imaging, and positive findings were examined. A modified Poisson regression approach was used to determine predictors of a proper evaluation before magnetic resonance imaging and positive findings on knee magnetic resonance imaging. RESULTS Orthopaedists and non-surgical sports physicians were significantly more likely to document a physical examination, to evaluate radiographs made prior to ordering a magnetic resonance image, and to identify positive findings on the magnetic resonance image (all p < 0.001). In multivariate models, orthopaedists were more likely to document a history of present illness (relative risk, 1.05; p = 0.043). Compared with primary care physicians, a physical examination was more likely to be documented by both non-surgical sports medicine physicians (relative risk, 1.61; p < 0.001) and orthopaedists (relative risk, 1.60; p < 0.001) and positive magnetic resonance imaging findings were more likely to be found by non-surgical sports medicine physicians (relative risk, 1.41; p = 0.012) and by orthopaedists (relative risk, 1.44, p = 0.009). Other independent predictors of a magnetic resonance imaging study with positive findings were the presence of an acute injury by history (relative risk, 2.04; p < 0.001) and younger age (relative risk, 0.99; p = 0.021). CONCLUSIONS Orthopaedists and non-surgical sports physicians are more likely to perform and to document a complete evaluation prior to ordering a knee magnetic resonance image with a positive finding. More musculoskeletal training may be useful to enable primary care physicians to use magnetic resonance imaging of the knee in a more efficient manner.
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Affiliation(s)
- James D Wylie
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108. E-mail address for J.D. Wylie:
| | - Julia R Crim
- Department of Radiology, University of Missouri, One Hospital Drive, DC069.00, Columbia, MO 65212
| | - Zachary M Working
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108. E-mail address for J.D. Wylie:
| | - Robert L Schmidt
- Department of Pathology, University of Utah, 30 North 1900 East, Room 5R441, Salt Lake City, UT 84132
| | - Robert T Burks
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108. E-mail address for J.D. Wylie:
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James EW, Williams BT, LaPrade RF. Stress radiography for the diagnosis of knee ligament injuries: a systematic review. Clin Orthop Relat Res 2014; 472:2644-57. [PMID: 24504647 PMCID: PMC4117881 DOI: 10.1007/s11999-014-3470-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Stress radiography is a widely used diagnostic tool to assess injury to the anterior and posterior cruciate ligaments and the medial and lateral structures of the knee. However, to date, numerous techniques have been reported in the literature with no clear consensus as to which methodology is best for assessing ligament stability. QUESTIONS/PURPOSES The purpose of this review was to identify which stress radiographic techniques have support in the literature for the diagnosis of acute or chronic knee ligament injuries, to define which technique is most accurate and reliable for diagnosing knee ligament injuries, and to compare the use of stress radiography with other diagnostic tests. METHODS Two independent reviewers performed a systematic review of PubMed (MEDLINE), the EMBASE library, and the Cochrane Controlled Trials Register for English language studies published from January 1970 to August 2013 on the diagnosis of knee ligament injuries using stress radiography. Information describing the ligament(s) investigated, stress radiographic technique, magnitude of force, measures of accuracy and reliability, and comparative diagnostic tests were extracted. Risk of bias was assessed using the QUADAS-2 tool. RESULTS A total of 16 stress techniques were described for stress radiography of the knee. The diagnostic accuracy of stress radiography including the sensitivity, specificity, and positive and negative predictive values varied considerably depending on the technique and choice of displacement or gapping threshold. Excellent reliability was reported for the diagnosis of anterior cruciate ligament, posterior cruciate ligament, varus, and valgus knee injuries. Inconsistencies were found across studies regarding the efficacy of stress radiography compared with other diagnostic modalities. CONCLUSIONS Based on the multitude of stress techniques reported, varying levels of diagnostic accuracy, and inconsistencies regarding comparative efficacy of stress radiography to other diagnostic modalities, we are not able to make specific recommendations with regard to the best stress radiography technique for the diagnosis of knee ligament injuries. Additional comparative studies using consistent methodology and appropriate blinding are necessary to further define differences in accuracy and reliability both among stress radiography techniques and between stress radiography and other diagnostic tests. LEVEL OF EVIDENCE Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Evan W. James
- />Center for Outcomes-based Orthopaedic Research, Steadman Philippon Research Institute, Vail, CO USA
| | - Brady T. Williams
- />Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, CO USA
| | - Robert F. LaPrade
- />The Steadman Clinic, 181 W Meadow Drive, Suite 400, Vail, CO 81657 USA
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Swain MS, Henschke N, Kamper SJ, Downie AS, Koes BW, Maher CG. Accuracy of clinical tests in the diagnosis of anterior cruciate ligament injury: a systematic review. Chiropr Man Therap 2014; 22:25. [PMID: 25187877 PMCID: PMC4152763 DOI: 10.1186/s12998-014-0025-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 06/22/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Numerous clinical tests are used in the diagnosis of anterior cruciate ligament (ACL) injury but their accuracy is unclear. The purpose of this study is to evaluate the diagnostic accuracy of clinical tests for the diagnosis of ACL injury. METHODS STUDY DESIGN Systematic review. The review protocol was registered through PROSPERO (CRD42012002069). Electronic databases (PubMed, MEDLINE, EMBASE, CINAHL) were searched up to 19th of June 2013 to identify diagnostic studies comparing the accuracy of clinical tests for ACL injury to an acceptable reference standard (arthroscopy, arthrotomy, or MRI). Risk of bias was appraised using the QUADAS-2 checklist. Index test accuracy was evaluated using a descriptive analysis of paired likelihood ratios and displayed as forest plots. RESULTS A total of 285 full-text articles were assessed for eligibility, from which 14 studies were included in this review. Included studies were deemed to be clinically and statistically heterogeneous, so a meta-analysis was not performed. Nine clinical tests from the history (popping sound at time of injury, giving way, effusion, pain, ability to continue activity) and four from physical examination (anterior draw test, Lachman's test, prone Lachman's test and pivot shift test) were investigated for diagnostic accuracy. Inspection of positive and negative likelihood ratios indicated that none of the individual tests provide useful diagnostic information in a clinical setting. Most studies were at risk of bias and reported imprecise estimates of diagnostic accuracy. CONCLUSION Despite being widely used and accepted in clinical practice, the results of individual history items or physical tests do not meaningfully change the probability of ACL injury. In contrast combinations of tests have higher diagnostic accuracy; however the most accurate combination of clinical tests remains an area for future research. CLINICAL RELEVANCE Clinicians should be aware of the limitations associated with the use of clinical tests for diagnosis of ACL injury.
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Affiliation(s)
- Michael S Swain
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia ; Department of Chiropractic, Faculty of Science, Macquarie University, Sydney, 2109, Australia
| | - Nicholas Henschke
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia ; Institute of Public Health, University of Heidelberg, Heidelberg, 69120, Germany
| | - Steven J Kamper
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia ; Department of Epidemiology and Biostatistics, EMGO + Institute, VU University Medical Center, Amsterdam, 1081BT, Netherlands
| | - Aron S Downie
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia ; Department of Chiropractic, Faculty of Science, Macquarie University, Sydney, 2109, Australia
| | - Bart W Koes
- Department of General Practice, Erasmus MC, University Medical Centre, Rotterdam, 50 3015 GE, Netherlands
| | - Chris G Maher
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia
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Swart NM, van Oudenaarde KK, Algra PR, Bindels PJE, van den Hout WB, Koes BW, Nelissen RGHH, Verhaar JAN, Bloem HJL, Bierma-Zeinstra SMA, Reijnierse MM, Luijsterburg PAJ. Efficacy of MRI in primary care for patients with knee complaints due to trauma: protocol of a randomised controlled non-inferiority trial (TACKLE trial). BMC Musculoskelet Disord 2014; 15:63. [PMID: 24588860 PMCID: PMC3973891 DOI: 10.1186/1471-2474-15-63] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 02/27/2014] [Indexed: 11/12/2022] Open
Abstract
Background Patients with traumatic knee complaints regularly consult their general practitioner (GP). MRI might be a valuable diagnostic tool to assist GPs in making appropriate treatment decisions and reducing costs. Therefore, this study will assess the cost-effectiveness of referral to MRI by GPs compared with usual care, in patients with persistent traumatic knee complaints. Design and methods This is a multi-centre, open-labelled randomised controlled non-inferiority trial in combination with a concurrent observational cohort study. Eligible patients (aged 18–45 years) have knee complaints due to trauma (or sudden onset) occurring in the preceding 6 months and consulting their GP. Participants are randomised to: 1) an MRI group, i.e. GP referral to MRI, or 2) a usual care group, i.e. no MRI. Primary outcomes are knee-related daily function, medical costs (healthcare use and productivity loss), and quality of life. Secondary outcomes are disability due to knee complaints, severity of knee pain, and patients’ perceived recovery and satisfaction. Outcomes are measured at baseline and at 1.5, 3, 6, 9 and 12 months follow-up. Also collected are data on patient demographics, GPs’ initial working diagnosis, GPs’ preferred management at baseline, and MRI findings. Discussion In the Netherlands, the additional diagnostic value and cost-effectiveness of direct access to knee MRI for patients presenting with traumatic knee complaints in general practice is unknown. Although GPs increasingly refer patients to MRI, the Dutch clinical guideline ‘Traumatic knee complaints’ for GPs does not recommend referral to MRI, mainly because the cost-effectiveness is still unknown. Trial registration Dutch Trial Registration: NTR3689.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Pim A J Luijsterburg
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.
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Inderhaug E, Strand T, Fischer-Bredenbeck C, Solheim E. Long-term results after reconstruction of the ACL with hamstrings autograft and transtibial femoral drilling. Knee Surg Sports Traumatol Arthrosc 2013; 21:2004-10. [PMID: 23223948 DOI: 10.1007/s00167-012-2330-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 11/26/2012] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate the long-term clinical, patient-reported and radiological outcome of patients reconstructed for anterior cruciate ligament (ACL) insufficiency. We wanted to examine the relationship between clinical findings and patient-reported scores. METHODS The 96 first successive patients that underwent ACL reconstruction using transtibial technique, hamstrings autograft and tunnel placement ad modum Howell were evaluated 10 years post-operatively. Subjective outcomes were Lysholm score, IKDC 2000 subjective score and Tegner activity scale. The clinical examination included evaluation of rotational and sagittal laxity. Evaluation of osteoarthritis was done radiologically. RESULTS Eighty-three patients (86%) were available for follow-up at mean 10.2 years post-operatively. Three patients had revision ACL surgery prior to the 10-year evaluation. The mean Lysholm score, subjective IKDC 2000 score and Tegner activity scale were 89 (SD 13), 83 (SD 15) and 5 (range, 3-9), respectively. Six patients (8%) had moderate or severe osteoarthritis. Eighty-six per cent of patients had normal or near-normal anterior-posterior ACL laxity. Twenty per cent of patients had positive pivot shift and 42 % had a pivot glide. The former group had a significant lower Lysholm score compared to the rest of the patients. CONCLUSIONS Although the mean Lysholm score was classified as good (89) at the 10-year follow-up, a positive pivot shift was found in 20% of these patients. Compared to patients with normal rotational laxity or pivot glide, this patient group reported significant lower subjective satisfaction at the long-term follow-up. LEVEL OF EVIDENCE Case series, level IV.
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Affiliation(s)
- Eivind Inderhaug
- Surgical Department, Haraldsplass Deaconess Hospital, Pb 6165, 5152, Bergen, Norway.
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Schmale GA. Adolescent knee pain management. Pediatr Ann 2013; 42:122-7. [PMID: 23458872 DOI: 10.3928/00904481-20130222-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
BACKGROUND Prognosis of persistent complaints after knee injury is based on secondary care populations. In a primary care setting, however, no studies have addressed this issue. AIM To identify possible predictors of persistent complaints 1 year after a knee injury. These predictors are important for guiding the GP's therapeutic management, and giving advice to patients about work and/or sports-related activities. DESIGN AND SETTING Primary care prospective cohort study with a 1-year follow-up period in five municipalities in the southwest region of the Netherlands. METHOD Patients who were eligible were recruited to the study by a GP research network with around 84,000 patients and 40 participating GPs. A total of 134 patients (aged 18-65 years) who consulted their GP within 5 weeks after a knee injury entered the study. Follow-up after 1 year was conducted in 122 patients. The main outcome was persistent complaints 1 year after injury; possible predictors for these complaints were obtained with a questionnaire, a physical examination, and magnetic resonance imaging (MRI), according to a standardised protocol. RESULTS After 1 year, of the 122 available patients, 21 (17%) reported persistent complaints and 101 (83%) reported full recovery or major improvement. In this study being aged >40 years had a significant association (P<0.05) with persistent complaints (odds ratio 8.0, 95% confidence interval 2.1 to 30.5). Physical examination and MRI findings revealed no predictors that were associated with these complaints. CONCLUSION Being aged >40 years was the only determinant with a significant association with persistent complaints. As physical examination and MRI had no predictive value, they are not recommended for prognosis of persistent complaints.
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