Diagnostic Accuracy of Lever Sign Test in Acute, Chronic, and Postreconstructive ACL Injuries

Diagnostic accuracy of lever sign test in acute and chronic ACL injuries

Introduction

The anterior cruciate ligament (ACL) is a commonly affected knee ligament prone to frequent injuries. Henceforth, we aimed to determine the diagnostic accuracy of lever sign test in Acute and chronic ACL injuries.

Method

At the institution's initial outpatient visit, 150 consecutive patients (92 males and 58 females) were evaluated. Total 108 patients had injury in their right leg, whereas 42 had injury in their left leg. Based on time since injury, the patients were divided into Acute and chronic groups. Clinical examinations (lachman's test and lelli's test) of all patients were confirmed with arthroscopic findings and compared between the two groups.

Results

In the acute ACL injury, the lever test had a kappa value 0.704. The accuracy and sensitivity of the Lachman, anterior drawer, pivot shift, and lever tests were calculated. We found that the lever test had the highest accuracy and sensitivity (85.48 %, 91.18 %) than the rest. In the chronic ACL injury, the kappa value for the results of the Lachman test evaluation was 0.723. The chronic ACL injuries accuracy and sensitivity values for the Lachman (86.36 %, 91.67 %), anterior drawer (76.14 %, 81.25 %), pivot shift (55.68 %, 58.49 %), and lever tests were determined.

Conclusion

The lever sign test is more accurate and reliable in the acute ACL injuries, while the Lachman test is more accurate and reliable in the chronic ACL injuries.

Lever sign test shows high diagnostic accuracy for anterior cruciate ligament injuries: A systematic review and meta-analysis of 3299 observations

PURPOSE

Injuries of the anterior cruciate ligament (ACL) are common knee injuries among active and younger patients. The Lever Sign Test (LST) is a relatively newer test, of which the accuracy is disputed in the existing literature. The aim of this study was to assess the accuracy with and without anesthesia of the Lever Sign test in the literature.

METHODS

PRISMA guidelines were followed, studies were identified using PubMed, EMBASE and Google Scholar. All studies that reported accuracy of LST performed by a clinical professional were included. Integrity of ACL was confirmed using magnetic resonance imaging or arthroscopy. Sensitivity and specificity were calculated using uni- and bivariate methods.

RESULTS

After inclusion, 3299 observations in 2516 patients were included from 23 studies. Mean age was 31.8 years and 64.2% were male. Without anesthesia, sensitivity was 79.2% (95% CI 68.7-86.9) and specificity was 92.0% (95% CI 82.2-96.6). An area under the curve (AUC) of 86.1% was found. With anesthesia, sensitivity was 86.6% (95% CI 68.0-95.2), specificity was 93.4% (95% CI 84.5-97.3) and the AUC was 91.6%.

CONCLUSION

The Lever Sign test shows very good to excellent accuracy for ACL injury, and is a useful tool for clinical practice.

Lever sign test for anterior cruciate ligament injuries: a diagnostic meta-analysis

BACKGROUND

Sports-related ACL (anterior cruciate ligament) injuries are frequent. Successful management requires early diagnosis and treatment. One of the clinical tests used to identify ACL damage is the lever sign test. This meta-analysis aimed to assess the lever sign test's diagnostic efficacy for ACL injuries.

METHODS

An extensive investigation of the Cochrane Library, Embase, and PubMed databases was conducted until April 2023. Studies assessing the lever sign test's diagnostic efficacy for ACL injuries were also included. A bivariate random-effects model was employed to acquire the pooled estimates of diagnostic odds ratios, specificity, positive and negative likelihood ratios, sensitivity, and curves of the summary receiver operating characteristic (SROC).

RESULTS

The meta-analysis comprised twelve investigations with a total of 1365 individuals. The lever sign test's combined sensitivity and specificity for the purpose of diagnosing injuries to the ACL were 0.810 (95% confidence interval [CI] 0.686-0.893) and 0.784 (95% CI 0.583-0.904), respectively. The positive and negative likelihood ratios were 3.148 (95% CI 1.784-5.553) and 0.210 (95% CI 0.084-0.528), respectively. The study revealed a diagnostic odds ratio of 17.656, with a 95% CI ranging from 4.800 to 64.951. The SROC curve's area was determined to be 0.912 (95% CI 0.857-0.967).

CONCLUSION

With high specificity and sensitivity, the lever sign test is a reliable diagnostic modality for ACL injuries. However, the test should be used in combination with other diagnostic tests to increase the accuracy of the diagnosis. Further investigations are warranted to assess the clinical practicability of the lever sign test in various populations and settings.

[Reliability and validity of the Lever Sign Test in suspected ligament and/or meniscus injuries of the knee: a comparison between an orthopaedist and a physical therapist]

INTRODUCTION

The purpose of this study was to investigate the intertester reliability and validity of the Lever Sign Test. Intertester reliability has received little attention in previous studies. In order to make comparisons with other studies, the intertester reliability and validity of the Lachman and Anterior Drawer Tests were also calculated.

PATIENTS/MATERIAL AND METHODS

Patients between 18 and 50 years of age with suspected ligament and/or meniscus injuries were included. Exclusion criteria were suspected malignant, systemic, or central neurologic disease, acute cartilage injury, suspected fracture, or knowledge of the participant's knee findings. Testing was randomized and blinded by an experienced orthopaedic surgeon and a physical therapist. Cohen's kappa was calculated for intertester reliability. Sensitivity and specificity, positive and negative predictive value, and positive and negative likelihood ratio were calculated. MRI findings were used as the gold standard.

RESULTS

Thirty-six patients were enrolled in the study, 27 male (75%) and 9 female (25%). The prevalence of anterior cruciate ligament lesions was 44.4%. Cohen's kappa (κ) was κ=0.6 (CI 95% [0.29, 0.91]) for the Lever Sign Test, κ=0.64 (CI 95% [0.35, 0.93]) for the Lachman test, and κ=0.63 (CI 95% [0.3, 0.95]) for the Anterior Drawer Test. The sensitivity of the Lever Sign Test was 0.53 and 0.40 for the orthopaedic surgeon and physical therapist, respectively, specificity was 0.89 and 0.79, the positive predictive value was 0.80 and 0.60, the negative predictive value was 0.70 and 0.62, the positive likelihood ratio was 4.80 and 1.90, respectively, and the negative likelihood ratio was 0.76 and 0.53.

CONCLUSION

The estimated intertester reliability of the Lever Sign Test was good. The Lever Sign Test is suitable as a complement to the Lachman Test, which is considered the most valid test in the literature. The weaknesses and ambiguities of the operating mechanism of the Lever Sign Test should not be ignored and should be further explored.

Clinical Reproducibility and Reliability of Lever Sign (Lelli's) Test for Acute ACL Tear Performed by Medical Students

BACKGROUND

Injuries to the anterior cruciate ligament (ACL) in sports are frequent in children and young adults participating in sporting activities involving rotational and pivoting movements. Magnetic resonance imaging is the most accurate diagnostic tool to detect an ACL tear. There are, however, a number of specialized tests available to assess ACL competency.

HYPOTHESIS

A novel test was described with extremely high clinical accuracy. The purpose of this study was to assess its clinical accuracy when performed by non-orthopedic providers, such as medical students.

METHODS

A cross-sectional study design was adopted, and two patients with an MRI-proven complete ACL tear were selected. One patient was thin, and the other was overweight, and both were examined by 100 medical students for both the injured and uninjured knee. The results for these exams were recorded, and a statistical analysis of the screening test was done to evaluate the new special test.

RESULTS

Our results were different from the ones found in the literature: we found the test to have a significantly lower performance in terms of sensitivity, specificity, and positive and negative likelihood ratios compared to the literature numbers.

CONCLUSION

The Lever sign (Lelli's) test loses clinical credibility and significance when performed by non-orthopedic providers or doctors, such as medical students in our study.

Clinical Examination in the Diagnosis of Anterior Cruciate Ligament Injury: A Blinded, Cross-sectional Evaluation

OBJECTIVE

This study was conducted to compare the effectiveness of clinical tests for anterior cruciate ligament (ACL) injury.

METHODS

This study prospectively evaluated the effectiveness of the Lachman test, anterior drawer test, and lever test in diagnosing ACL injury in 133 patients with knee pathology. The examiner was blinded to the patient's history, symptoms, and laterality of the pain at the time of examination. One hundred twenty-three patients in the study underwent MRI, and 90 went on to arthroscopy. The performance of the examination maneuvers and MRI was calculated.

RESULTS

This study showed notable differences in sensitivity and specificity between the Lachman test and the lever test and in specificity between the anterior drawer test and the lever test. The Lachman test was also found to be more sensitive than the anterior drawer. All ACL tears diagnosed by a composite of the physical examination maneuvers were confirmed by MRI. MRI findings were concordant with arthroscopic findings in all cases.

CONCLUSIONS

The Lachman test and the anterior draw test demonstrated clinical utility, but the results of the lever test should be interpreted with caution. Clinical examination was found to be highly specific but less sensitive than MRI.

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

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.

Consensus Delphi study on guidelines for the assessment of anterior cruciate ligament injuries in children

Background: Knee examination guidelines in minors are intended to aid decision-making in the management of knee instability. Clinical question: A Delphi study was conducted with a formal consensus process using a validated methodology with sufficient scientific evidence. A group consensus meeting was held to develop recommendations and practical guidelines for use in the assessment of instability injuries in children. Key findings: there is a lack of evidence to analyse anterior cruciate ligament injuries in children and their subsequent surgical management if necessary. Diagnostic guidelines and clinical assessment of the patient based on a thorough examination of the knee are performed and a guide to anterior cruciate ligament exploration in children is developed. Clinical application: In the absence of a strong evidence base, these established guidelines are intended to assist in that decision-making process to help the clinician decide on the most optimal treatment with the aim of benefiting the patient as much as possible. Following this expert consensus, surgical treatment is advised when the patient has a subjective sensation of instability accompanied by a pivot shift test ++, and may include an anterior drawer test + and a Lachman test +. If these conditions are not present, the conservative approach should be chosen, as the anatomical and functional development of children, together with a physiotherapy programme, may improve the evolution of the injury.

Value of clinical tests in diagnosing anterior cruciate ligament injuries: A systematic review and meta-analysis

OBJECTIVES

This study compared 4 clinical tests with reference to magnetic resonance imaging and arthroscopic visualization to comprehensively evaluate their diagnostic value for anterior cruciate ligament injuries.

METHODS

We systematically searched 10 electronic databases from January 1, 2010, to May 1, 2021. Two reviewers collected data in accordance with the Preferred Reporting Item for Systematic Reviews and Meta-Analyses 2020 guidelines. The quality of each study was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. A meta-analysis was performed using Meta-Disc version 1.4 and Stata SE version 15.0.

RESULTS

Eighteen articles involving 2031 participants were included. The results of the meta-analysis showed that for the Lachman test, the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnosis odds ratio, area under the curve (AUC) of summary receiver operating characteristic (SROC), and Q* were 0.76 (95% CI, 0.73-0.78), 0.89 (95% CI, 0.87-0.91), 5.65 (95% CI, 4.05-7.86), 0.28 (95% CI, 0.23-0.36), 22.95 (95% CI, 14.34-36.72), 0.88, and 0.81, respectively. For the anterior drawer test, the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnosis odds ratio, AUC of SROC, and Q* were 0.64 (95% CI, 0.61-0.68), 0.87 (95% CI, 0.84-0.90), 3.57 (95% CI, 2.13-5.96), 0.44 (95% CI, 0.32-0.59), 8.77 (95% CI, 4.11-18.74), 0.85, and 0.78, respectively. For the pivot shift test, the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnosis odds ratio, AUC of SROC, and Q* were 0.59 (95% CI, 0.56-0.62), 0.97 (95% CI, 0.95-0.98), 13.99 (95% CI, 9.96-19.64), 0.44 (95% CI, 0.35-0.55), 29.46 (95% CI, 15.60-55.67), 0.98, and 0.94, respectively. For the lever sign test, the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnosis odds ratio, AUC of SROC, and Q* were 0.79 (95% CI, 0.75-0.83), 0.92 (95% CI, 0.87-0.95), 9.56 (95% CI, 2.76-33.17), 0.23 (95% CI, 0.12-0.46), 47.38 (95% CI, 8.68-258.70), 0.94, and 0.87, respectively.

CONCLUSIONS

Existing evidence shows that these clinical tests have high diagnostic efficacy for anterior cruciate ligament injuries, and that every test has its own advantages and disadvantages. However, the above results should be validated through additional studies, considering the limited quality and quantity of our sample.

Diagnostic Accuracy of Physical Examination Tests for Suspected Acute Anterior Cruciate Ligament Injury: A Systematic Review and Meta-Analysis

Background

Many tests are used to examine the knee when anterior cruciate ligament (ACL) injury is suspected. However, evidence of diagnostic accuracy in the Lachman, anterior drawer, pivot shift, and lever sign tests is limited.

Purpose

The purpose of this study was to perform a systematic review and meta-analysis of original research studies that assessed the diagnostic accuracy of four physical examination tests for ACL injury acutely after an injury.

Study design

Systematic review and meta-analysis.

Methods

A literature search was conducted in the PubMed, MEDLINE, CINAHL, Web of Science, and Ichushi databases. Original articles with prospective cohort and cross-sectional studies in English and Japanese were included. The searched words were "anterior cruciate ligament", "injury"," rupture"," tear", "lachman test", "pivot shift test", "anterior drawer test", "lever sign test". The methodological quality of the diagnostic studies was evaluated using QUADAS-2. Summary sensitivity, specificity, likelihood ratio (LR)+, and LR- with 95% confidence intervals were calculated.

Results

Eight studies were included in this review. The methodological quality of the included studies was mostly favorable. For the domain of flow and timing in the QUADAS-2, three studies did not assess the timing between the reference and index tests. The pooled sensitivities were 0.79, 0.78, 0.55, and 0.82 in the Lachman, anterior drawer, pivot shift, and lever sign tests, respectively, and the pooled specificities were 0.91, 0.91, 0.96, and 0.88, respectively. The lever sign test had the lowest LR- (0.21) and the pivot shift test had the highest LR+ (11.60). The area under the curve for the four physical examinations was > 0.70.

Conclusion

The lever sign and pivot shift tests are useful for diagnosing ACL injuries in an acute setting.

Level of Evidence

Level 2.

Validity of the lever sign test for the clinical diagnosis of anterior cruciate ligament tears: Assessments in ski resorts

INTRODUCTION

The clinical diagnosis of an anterior cruciate ligament (ACL) tear is based on 3 tests: anterior drawer, pivot shift and Lachman. The latter is the most commonly used test. The "lever sign" is a new clinical test that was first described by Lelli et al. in 2014. The primary objective of this study was to determine the sensitivity of the lever sign test for the clinical diagnosis of ACL tears, in the primary care setting of patients with acute knee injuries. Primary care being the first point of contact between patients and the healthcare system (general practitioners in this study). The secondary objective was to calculate the positive predictive value (PPV) of the lever sign test, by comparing it to the PPV of the Lachman test and its sensitivity. The working hypothesis was that the sensitivity of the lever sign test was equal to or greater than 80%.

METHODS

This prospective cohort study included patients with ski-related knee injuries which occurred in French ski resorts between December 1, 2019, and March 15, 2020. The Lachman test and the lever sign test were performed by 36 mountain physicians and were compared to the magnetic resonance imaging (MRI) findings. The lever sign test involved placing a closed fist under the patient's calf in the supine position and applying downward pressure over the quadriceps. Depending on whether the ACL was intact or not, the patient's heel would either rise off the examination table or remain still. This study included 258 patients: 190 women and 68 men.

RESULTS

The MRIs found 219 ACL tears and 36 intact ACLs. Three MRIs were deemed uninterpretable. The sensitivity of the lever sign test was 61.2% and the PPV was 83.8%. The sensitivity of the Lachman test was 99.1% and the PPV was 86.5%.

CONCLUSION

This study determined the sensitivity of the lever sign test for the clinical diagnosis of ACL tears during real-life situations encountered by mountain physicians. This sensitivity was lower than expected. The Lachman test, on the other hand, showed a very high sensitivity. It remains the test of choice for the clinical diagnosis of ACL tears in patients with knee injuries. Therefore, the lever sign test can complement the Lachman test but is not a substitute for it.

LEVEL OF EVIDENCE

II.

Is Lever Test Superior to Lachman, Pivot Shift, Drawer Tests in Diagnosing Anterior Cruciate Ligament Injuries?

Introduction: The physical examination in anterior cruciate ligament (ACL) injuries is extremely important, and the Lever test is commonly utilized on ACL evaluation. However, the number and scope of studies on the Lever test is limited. In this prospective cross-sectional study, we aimed to evaluate the effectiveness of the diagnostic values of Lachman, Pivot Shift, Lever, and Anterior Drawer tests in terms of quadriceps atrophy and case phase in ACL injuries.

Methods: In this prospective study, diagnostic values of Lachman, Pivot Shift, Lever, and Anterior Drawer tests were examined on 189 patients with positive MRI results as the gold standard.

Results: Lever test positivity was significantly more frequent in the group with quadriceps atrophy preoperative and after sedation (p<0.05). Anterior Drawer test positivity was significantly more frequent in the group with positive quadriceps atrophy preoperatively, after sedation and after spinal anesthesia (p<0.05). Lever and Anterior Drawer tests were positively correlated with quadriceps atrophy preop and after sedation (p<0.05). Lever test before surgery, after sedation and after spinal anesthesia in the chronic patient group was more positive than in the acute and subacute groups (p<0.05). Lever test was positively correlated with phase preoperatively, after sedation and after spinal anesthesia (p<0.01).

Conclusion: The presence or absence of quadriceps atrophy in patients with acute, sub-acute, or chronic ACL injury has a significant effect on the predictive value of the Lever test. We think that univariate analyzes may give incorrect results when demonstrating predictive value, and it would be more correct to perform multivariate analyzes.