Anterior cruciate ligament rupture: Delay to diagnosis

Anodal tDCS improves the effect of neuromuscular training on the feedforward activity of lower extremity muscles in female taekwondo athletes with dynamic knee valgus

Transcranial direct current stimulation (tDCS) can increase cortical excitability of a targeted brain area. This study aimed to investigate the effect of adding anodal-tDCS (a-tDCS) to neuromuscular training (NMT) on the dynamic knee valgus (DKV) and feedforward activity (FFA) of knee muscles. Thirty-four Taekwondo athletes with DKV, were randomly assigned to either NMT + a-tDCS (N = 17) or NMT + sham tDCS (N = 17). DKV and the knee muscles' FFA at the moment of single and double-leg landing and lateral hopping tasks were evaluated before and after the interventions. DKV and FFA of the knee muscles was improved in all tasks (P < 0.05), however, between-group differences were not significant (P > 0.05). The FFA of the semitendinosus, vastus medialis, gluteus medius, and gastrocnemius muscles in the single-leg landing (P < 0.05), the gluteus medius, gluteus maximus, semitendinosus, biceps femoris, and gastrocnemius muscles in the double-leg landing (P < 0.05), and the gluteus medius, gluteus maximus, and gastrocnemius muscles in the lateral hopping (P < 0.05) tasks were significantly different between the groups. A-tDCS achieved significantly larger improvements in the feedforward activity of lower extremity muscles compared with sham-tDCS. However, between-group comparisons did not show a significant difference in DKV.

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

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.

Point-of-Care Ultrasound for the Evaluation and Management of Posterior Cruciate Ligament Injuries: A Systematic Review

Posterior cruciate ligament (PCL) injuries, though less common than other knee ligament injuries, pose significant management challenges. This study aimed to systematically review and analyze the current evidence on the use of point-of-care ultrasound (POCUS) for the evaluation and management of PCL injuries. It was hypothesized that POCUS has comparable diagnostic accuracy to magnetic resonance imaging (MRI) and that the use of POCUS improves patient outcomes and reduces healthcare costs. A comprehensive systematic review of articles published up to April 2023 was conducted using PubMed, Web of Science, Cochrane, and Scopus databases and adhered to the PRISMA guidelines. Studies were selected based on relevance to the research question, with a focus on diagnostic accuracy, reliability, clinical utility, and cost-effectiveness of POCUS in PCL injuries. Seven studies, analyzing a total of 242 patients with PCL injuries, were included. The reported sensitivity and specificity of POCUS for diagnosing PCL injuries ranged from 83.3% to 100% and 86.7% to 100%, respectively, across the studies. In one study, POCUS demonstrated a positive predictive value (PPV) of 87.9% and a negative predictive value (NPV) of 82.4%. Additionally, three studies reported 100% accuracy in PCL injury detection using POCUS, suggesting a substantial potential for cost savings by eliminating the need for MRI. This systematic review supports the use of POCUS in the evaluation and management of PCL injuries, suggesting that POCUS is a reliable, cost-effective tool with high diagnostic accuracy comparable to that of MRI, offering the potential to improve patient outcomes and reduce healthcare costs. The data collated in this review can inform clinical practice and guide future research in the field.

Is MRI Overutilized for Evaluation of Knee Pain in Veterans?

MRI is an essential diagnostic imaging modality for many knee conditions; however, it is not indicated in the setting of advanced knee arthritis. Inappropriate MRI imaging adds to health care costs and may delay definitive management for many patients. The primary purpose of this study was to ascertain the frequency of inappropriate MRI scans performed at one Veterans' Administration Medical Center (VAMC). We performed a retrospective chart review of all knee MRIs ordered over a 6-month period. Inappropriate MRI was defined as MRI performed prior to radiographs (XRs), or in the presence of XRs demonstrating severe osteoarthritis, without leading to a nonarthroplasty procedure of the knee. Of the 304 cases reviewed, 36.8% (112) of the MRIs were deemed inappropriate, 33 were ordered by orthopedists, and 79 were ordered by other health care providers. Of the 33 ordered by orthopedists, 25 were ordered by retired/nonsurgical orthopedists. Obtaining an MRI delayed care by an average of 29.2 days. Of the 252 cases that had XR prior to MRI, none included all four views in the standard knee XR series and only four had weightbearing images. Over a third of knee MRIs performed at this VAMC were inappropriate and delayed care. Additionally, no XRs in our study contained all the necessary views to properly assess knee arthritis. These concerning findings signify a potential opportunity for education in diagnostic strategies, to better patient care and resource utilization in the VAMC.

Prone Lachman with Ultrasound: A Literature Review and Description of the Technique

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.

Higher sensitivity with the lever sign test for diagnosis of anterior cruciate ligament rupture in the emergency department

INTRODUCTION

The objective of this study was to assess the diagnostic value of the "lever sign test" to diagnose ACL rupture and to compare this test to the two most commonly used, the Lachman and anterior drawer test.

METHOD

This prospective study was performed in the ED of the Cliniques Universitaires Saint-Luc (Brussels, Belgium) from March 2017 to May 2019. 52 patients were included undergoing knee trauma, within 8 days, with an initial radiograph excluding a fracture (except Segond fracture or tibial spine fracture). On clinical investigation, patients showed a positive lever sign test and/or a positive Lachman test and/or a positive anterior drawer test. Exclusion criteria were a complete rupture of the knee extensor mechanism and patellar dislocation. All the physicians involved in this study were residents in training. An MRI was performed within 3 weeks for all included patients after the clinical examination. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were investigated for all three tests with MRI used as our reference standard.

RESULTS

Forty out of 52 patients suffered an ACL rupture (77%) and 12 did not (23%). The sensitivity, specificity, PPV and NPV of the lever sign test were respectively 92.5%, 25% 82% and 50%. Those of the Lachman test were 54%, 54.5%, 81% and 25%, and those of the anterior drawer test were 56%, 82%, 90.5% and 37.5%. Twelve out of 40 ACL ruptures (30%) were diagnosed exclusively with a positive lever sign test.

CONCLUSION

When investigating acute ACL ruptures (< 8 days) in the ED, the lever sign test offers a sensitivity of 92.5%, far superior to that of other well-known clinical tests. The lever sign test is relatively pain-free, easy to perform and its visual interpretation requires less experience. Positive lever sign test at the ED should lead to an MRI to combine high clinical sensitivity with high MRI specificity.

Evaluating the diagnostic pathway for acute ACL injuries in trauma centres: a systematic review

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.

Acute knee clinics are effective in reducing delay to diagnosis following anterior cruciate ligament injury

BACKGROUND

Delays to diagnosis of anterior cruciate ligament (ACL) injury and specialist consultation continue to place patients at risk of early onset osteoarthritis. Incorporating acute knee clinics within a streamlined accident and emergency (A&E) pathway have shown potential in reducing delay but specific evaluative research is lacking. The aim of this service evaluation was to investigate the effectiveness of an acute knee clinic at one NHS Trust in the United Kingdom (UK), on reducing the delay to diagnosis of ACL injury and specialist consultation compared to a standard A&E pathway.

METHODS

An uncontrolled before and after design was utilised for this service evaluation. Data were collected from historical electronic patient records over a 1-year period with analysed results compared against previously collected data from the same NHS Trust.

RESULTS

81 records met the criteria for the streamlined A&E pathway and were compared against 50 from the standard A&E pathway. For the streamlined A&E pathway median delay to diagnosis reduced from 97 to 14 days and delay to specialist consultation reduced from 158.5 to 45 days and were of statistical significance. The incorporation of an acute knee clinic was identified as the most influential factor on delay in addition to the location of presentation and mechanism of injury.

CONCLUSIONS

Introducing an acute knee clinic within a streamlined A&E pathway has a clinically relevant effect on reducing delay to diagnosis and specialist consultation and allows findings to be extrapolated and implemented to all UK based NHS Trust A&E departments.

Efficiency of knee ultrasound for diagnosing anterior cruciate ligament and posterior cruciate ligament injuries: a systematic review and meta-analysis

OBJECTIVE

To evaluate the diagnostic performance of knee ultrasound for anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries.

MATERIALS AND METHODS

PubMed and EMBASE databases were searched for diagnostic accuracy studies that used ultrasound for diagnosing ACL and PCL injuries. Bivariate and hierarchical summary receiver operating characteristic modeling was used to evaluate diagnostic performance. Subgroup analysis was performed by assessing studies conducted using the ultrasound technique (functional ultrasound versus conventional ultrasound) for diagnosing ACL injury. We performed meta-regression analyses for a potential source of heterogeneity.

RESULTS

Eleven (938 ultrasound/878 patients) and six articles (281 ultrasound/237 patients) were included for ACL and PCL injuries respectively. The summary sensitivity, summary specificity, and area under the hierarchical summary receiver operating characteristic for ACL and PCL injuries were 0.88 (95% confidence interval [CI], 0.81-0.93) and 0.99 (95% CI, 0.49-1.00), 0.96 (95% CI, 0.91-0.98) and 0.99 (95% CI, 0.73-1.00), and 0.97 (95% CI, 0.96-0.98) and 1.00 (95% CI, 0.99-1.00) respectively. In subgroup analysis, there was no significant difference between sensitivity (p = 0.63) and specificity (p = 0.72) of functional and conventional ultrasound. Among the various potential covariates, patient enrollment, patient position, and ultrasound performer were associated with heterogeneity in terms of sensitivity, and proportion of the ACL injury was associated with heterogeneity in terms of specificity.

CONCLUSION

Knee ultrasound demonstrates high diagnostic performance for ACL and PCL injuries, particularly when performed by experienced musculoskeletal radiologists. Future prospective studies to compare the cost- and time-effectiveness between ultrasound and magnetic resonance imaging and to determine the optimal ultrasound parameters are warranted.

Feasibility of point-of-care knee ultrasonography for diagnosing anterior cruciate and posterior cruciate ligament tears in the ED

OBJECTIVE

To evaluate the feasibility of point-of-care knee ultrasonography (POCUS) compared with knee magnetic resonance imaging (MRI) for diagnosing anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) tears in patients with acute knee trauma.

MATERIAL AND METHODS

A prospective study was conducted in a tertiary hospital emergency department; acute (within 1-week) knee trauma patients with suspected ACL or PCL tear were recruited. Two POCUS performers (a board-certified emergency physician and a musculoskeletal radiologist) independently evaluated the ACL and PCL using POCUS. Findings were classified as normal appearance or ligament tear. Final radiology reports of knee MRI were used as the reference standard. We calculated the diagnostic values (sensitivity, specificity, and accuracy) for POCUS obtained by both POCUS performers. Kappa values (k) were calculated for inter-observer agreement between the two POCUS performers.

RESULTS

Sixty-two patients were enrolled. Compared with the reference standard, POCUS showed acceptable sensitivity (90.6-100%), specificity (90.0-97.7%), and accuracy (91.9-96.8%). Inter-observer agreement between the two POCUS performers was excellent (k = 0.853-0.903).

CONCLUSION

POCUS demonstrates excellent precision as compared to MRI in the diagnosis of ACL and PCL tears. The findings of POCUS could be used for immediate diagnosis and further pre-operative imaging in patients with acute knee trauma.

Diagnosis of Simultaneous Acute Ruptures of the Anterior Cruciate Ligament and Posterior Cruciate Ligament Using Point-of-Care Ultrasound in the Emergency Department

BACKGROUND

Patients with acute anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries from sport-related activities are frequently seen in the emergency department (ED). However, knee instability tests are known to show variable sensitivity and specificity. These tests would also have limited functionality in patients with severe pain and swelling in the knee.

CASE REPORT

A 19-year-old female judo player presented to the ED with severe left knee pain. She had abruptly twisted her left knee while she was shoulder-throwing her opponent. She complained of severe pain and refused physical examination of the knee injury; as a result, evaluation of knee instability could not be performed. However, a point-of-care ultrasound helped in making a prompt and accurate diagnosis of simultaneous, complete rupture and partial ruptures of the ACL and PCL, respectively. The ultrasound findings correlated well with the magnetic resonance imaging images in the assessment of the combined ACL-PCL ruptures. The patient underwent simultaneous arthroscopic ACL and PCL reconstruction with a hamstring tendon autograft and was discharged. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Point-of-care ultrasound imaging of the knee in trauma patients may be helpful for diagnosis of ACL and PCL injuries by augmenting findings of physical examinations in patients with severe pain and swelling in the knee. Ultimately, it may lead to more accurate diagnosis and treatment plans in knee trauma patients.

Diagnostic Tools for Acute Anterior Cruciate Ligament Injury: GNRB, Lachman Test, and Telos

Purpose

The purpose of this study is to compare the accuracy of the GNRB arthrometer (Genourob), Lachman test, and Telos device (GmbH) in acute anterior cruciate ligament (ACL) injuries and to evaluate the accuracy of each diagnostic tool according to the length of time from injury to examination.

Materials and Methods

From September 2015 to September 2016, 40 cases of complete ACL rupture were reviewed. We divided the time from injury to examination into three periods of 10 days each and analyzed the diagnostic tools according to the time frame.

Results

An analysis of the area under the curve (AUC) of a receiver operating characteristic curve showed that all diagnostic tools were fairly informative. The GNRB showed a higher AUC than other diagnostic tools. In 10 cases assessed within 10 days after injury, the GNRB showed statistically significant side-to-side difference in laxity (p＜0.001), whereas the Telos test and Lachman test did not show significantly different laxity (p=0.541 and p=0.413, respectively).

Conclusions

All diagnostic values of the GNRB were better than other diagnostic tools in acute ACL injuries. The GNRB was more effective in acute ACL injuries examined within 10 days of injury. The GNRB arthrometer can be a useful diagnostic tool for acute ACL injuries.

The role of ultrasonography in the diagnosis of anterior cruciate ligament injury: A systematic review and meta-analysis

To evaluate the value of ultrasonography in the diagnosis of anterior cruciate ligament injury (ACL injury) by conducting a systematic review and meta-analysis. A literature search was carried out in the Cochrane Library, Embase, Pubmed databases and included studies prior to April 2017. Based on inclusion and exclusion criteria, studies evaluating ultrasound to diagnose ACL injury were selected. MRI, arthroscopy and clinical-follow were considered the reference standards. The diagnostic accuracy of ultrasound was assessed using a combination of sensitivity, specificity, likelihood ratio (LR), post-test probability, diagnostic odds ratio (DOR) and by summarizing the area under the receiver operating characteristic (SROC) curve. A total of 4 studies involving 246 patients were eventually included in the analysis. In these four studies, the combined sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, post-test probability and DOR were 90.0% (95% CI: 77-96), 97% (95% CI: 90-99), 31.08 (95% CI: 8.75-110.41), 0.11 (95% CI: 0.05-0.24), 89% (3%) and 288.81 (95% CI: 78.51-1062.48), respectively. The area under the SROC curve was 0.98 (95% CI: 0.97-0.99). Our meta-analysis showed that ultrasound can play an important role in the diagnosis of ACL injury. Because of its high sensitivity, high specificity and high diagnostic ability, ultrasound should be a part of the standard diagnostic work-up of an ACL injury.

Test-retest reliability of repeated knee laxity measurements in the acute phase following a knee trauma using a Rolimeter

The purpose was to examine the test-retest reliability of the Rolimeter measurement procedure in the acute time phase, following a substantial knee trauma. In total, 15 participants with acute knee trauma were examined by one single observer at three different time-points with the Rolimeter using a maximum force. The selected time-points were: baseline (0–7 days after the trauma), midpoint (3–4 weeks after the trauma), and endpoint (3–4 weeks after the trauma). The anterior-posterior displacement was recorded where the endpoint evaluation was used as the reference value. The mean anterior laxity scores remained constant over the measurement time-points for both knees, with an anterior laxity that was 2.7 mm higher (on average) in the injured than the noninjured knee (9.5 mm vs. 6.8 mm). The mean difference (i.e., bias) between laxity scores, for the injured knee, measured at endpoint versus baseline was 0.2±1.0 mm and −0.2±1.1 mm when measured at endpoint versus midpoint, with average typical errors of 0.7 and 0.8 mm and intra-class correlations that were very strong (both r=~0.93). For the same comparisons on the noninjured knee, systematic bias was close to zero (0.1±0.3 and −0.1±0.3 mm, respectively), and both the intra-class correlations were almost perfect (r=~0.99). The current study implicates that repeated Rolimeter measurements are relatively reliable for quantifying anterior knee laxity during the acute time-phases following knee trauma. Hence, the Rolimeter, in combination with manual tests, seems to be a valuable tool for identifying anterior cruciate ligament injuries.

The use of history to identify anterior cruciate ligament injuries in the acute trauma setting: the 'LIMP index'

OBJECTIVE

To identify the injury history features reported by patients with anterior cruciate ligament (ACL) injuries and determine whether history may be used to identify patients requiring follow-up appointments from acute trauma services.

METHODS

Multisite cross-sectional service evaluation using a survey questionnaire design conducted in the UK. The four injury history features investigated were 'leg giving way at the time of injury', 'inability to continue activity immediately following injury', 'marked effusion' and 'pop (heard or felt) at the time of injury'(LIMP).

RESULTS

194 patients with ACL injury were identified, of which 165 (85.5%) attended an acute trauma service. Data on delay was available for 163 (98.8%) of these patients of which 120 (73.6%) had a follow-up appointment arranged. Patients who had a follow-up appointment arranged waited significantly less time for a correct diagnosis (geometric mean 29 vs 198 days; p<0.001) and to see a specialist consultant (geometric mean 61 vs 328 days; p<0.001). Using a referral threshold of any two of the four LIMP injury history features investigated, 95.8% of patients would have had a follow-up appointment arranged.

CONCLUSIONS

Findings support the value of questioning patients on specific injury history features in identifying patients who may have suffered ACL injury. Using a threshold of two or more of the four LIMP history features investigated would have reduced the percentage of patients inappropriately discharged by 22.2%. Evidence presented suggests that this would significantly reduce the time to diagnosis and specialist consultation minimising the chance of secondary complications.

Efficacy of knee joint aspiration in patients with acute ACL injury in the emergency department

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.

A systematic review and meta-analysis of the diagnostic accuracy of MRI for suspected ACL and meniscal tears of the knee

PURPOSE

To determine the diagnostic accuracy of magnetic resonance imaging (MRI) and ultrasound (US) in the diagnosis of anterior cruciate ligament (ACL), medial meniscus and lateral meniscus tears in people with suspected ACL and/or meniscal tears.

METHODS

MEDLINE, Web of Science and the Cochrane library were searched from inception to March 2014. All prospective studies of the diagnostic accuracy of MRI or US against arthroscopy as the reference standard were included in the systematic review. Studies with a retrospective design and those with evidence of verification bias were excluded. Methodological quality of included studies was assessed using the QUADAS-2 tool. A meta-analysis of studies evaluating MRI to calculate the pooled sensitivity and specificity for each target condition was performed using a bivariate model with random effects. Sub-group and sensitivity analysis were used to examine the effect of methodological and other study variables.

RESULTS

There were 14 studies included in the meta-analysis of the accuracy of MRI for ACL tears, 19 studies included for medial meniscal tears and 19 studies for lateral meniscal tears. The summary estimates of sensitivity and specificity of MRI were 87 % (95 % CI 77-94 %) and 93 % (95 % CI 91-96 %), respectively, for ACL tears; 89 % (95 % CI 83-94 %) and 88 % (95 % CI 82-93 %), respectively, for medial meniscal tears; and 78 % (95 % CI 66-87 %) and 95 % (95 % CI 91-97 %), respectively, for lateral meniscal tears. Magnetic field strength had no significant effect on accuracy. Most studies had a high or unclear risk of bias. There were an insufficient number of studies that evaluated US to perform a meta-analysis.

CONCLUSION

This study provides a systematic review and meta-analysis of diagnostic accuracy studies of MRI and applies strict exclusion criteria in relation to the risk of verification bias. The risk of bias in most studies is high or unclear in relation to the reference standard. Concerns regarding the applicability of patient selection are also present in most studies.

LEVEL OF EVIDENCE

III.

Anterior cruciate ligament injury: A persistently difficult diagnosis

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.

The use of magnetic resonance imaging in acute knee injuries can be reduced by non-physician expert clinics

INTRODUCTION

The routine use of magnetic resonance imaging (MRI) for the assessment of acute knee injuries is controversial. The goal of this study is to present an audit of patients seen in a dedicated Acute Knee Injury Clinic (AKIC) to determine the frequency and appropriateness of MRI utilization.

METHODS

A retrospective review identified all patients who had an MRI and a randomly selected control group without MRI. The MRI was classified based on whether it was ordered by the AKIC team or by an external clinician. The consensus-based 'Indications for Urgent MRI in Acute Soft Tissue Knee Problems' were applied to both groups. An MRI was considered appropriate if any of the indications were met.

RESULTS

The overall MRI utilization rate was 23% (142/611). Of the MRIs performed, 32% (46/142) met the indications. About 94% (33/35) of the MRIs ordered by the AKIC experts met the indications, compared to only 12% (13/107) of those ordered externally. No patients in the control group met the indications. Diagnoses were similar between groups.

DISCUSSION

These results suggest that application of guidelines by experts in knee evaluation can significantly reduce expensive MRI utilization in patients with acute knee injuries without negatively impacting the appropriate diagnosis and disposition.