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Yang S, Liu Y, Ma S, Ding C, Kong Z, Li H, Huang F, Chen H, Zhong H. Stress and strain changes of the anterior cruciate ligament at different knee flexion angles: A three-dimensional finite element study. J Orthop Sci 2024; 29:995-1002. [PMID: 37407345 DOI: 10.1016/j.jos.2023.05.015] [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: 07/30/2022] [Revised: 04/23/2023] [Accepted: 05/12/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE This study aimed to analyze the stress and strain changes of the anterior cruciate ligament (ACL) at different knee flexion angles using a three-dimensional finite element model. METHODS Computed tomography and magnetic resonance imaging scans were performed on the right knee of 30 healthy adult volunteers. The imaging data were used to construct a three-dimensional finite element model of the knee joint. The magnitude and concentration area of stress and strain of ACL at knee flexion angles 0°, 30°, 60° and 90° were assessed. RESULTS The magnitude of stress remained consistent at 0-30° (P > 0.999) and decreased at 30-90° (P < 0.001, P = 0.005, respectively), while the magnitude of strain increased between 0° and 30° (P = 0.004) and decreased between 30° and 90° (P < 0.001, P = 0.004, respectively). The stress concentration area remained consistent at the proximal end, midsubstance, and distal end between 0° and 60° (P > 0.05). The concentration area of strain increased at the proximal end, decreased at the midsubstance between 0° and 30°, and remained consistent between 30° and 90° (P < 0.001). CONCLUSION At the low knee flexion angle, ACL's magnitude of stress and strain reached the peak, and the concentration area of ACL strain gradually shifted from midsubstance to the proximal end.
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Affiliation(s)
- Shaozheng Yang
- Department of Orthopaedics, The Fifth Affiliated Hospital, Southern Medical University, Guangzhou, Guangdong Province, 510999, China.
| | - Yongqiang Liu
- Department of Orthopaedics, The Fifth Affiliated Hospital, Southern Medical University, Guangzhou, Guangdong Province, 510999, China.
| | - Sushuang Ma
- Department of Orthopaedics, The Fifth Affiliated Hospital, Southern Medical University, Guangzhou, Guangdong Province, 510999, China.
| | - Chao Ding
- Department of Orthopaedics, The Fifth Affiliated Hospital, Southern Medical University, Guangzhou, Guangdong Province, 510999, China.
| | - Zhen Kong
- Department of Orthopaedics, The Fifth Affiliated Hospital, Southern Medical University, Guangzhou, Guangdong Province, 510999, China.
| | - Heng Li
- Department of Orthopaedics, The Fifth Affiliated Hospital, Southern Medical University, Guangzhou, Guangdong Province, 510999, China.
| | - Feng Huang
- Department of Orthopaedics, The Fifth Affiliated Hospital, Southern Medical University, Guangzhou, Guangdong Province, 510999, China.
| | - Hongfen Chen
- Department of Orthopaedics, The Fifth Affiliated Hospital, Southern Medical University, Guangzhou, Guangdong Province, 510999, China.
| | - Hua Zhong
- Department of Orthopaedics, The Fifth Affiliated Hospital, Southern Medical University, Guangzhou, Guangdong Province, 510999, China.
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Kantrowitz DE, Colvin A. Comprehensive Clinical Examination of ACL Injuries. Clin Sports Med 2024; 43:311-330. [PMID: 38811112 DOI: 10.1016/j.csm.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
A comprehensive clinical examination of the potentially anterior cruciate ligament (ACL)-deficient knee should proceed as follows: inspection; palpation; range of motion; varus and valgus stress; neurovascular status; and finally provocative maneuvers. The Lachman, anterior drawer, Lever, and pivot shift tests are all greater than 90% specific for ACL pathology. Due to the relatively high coincidence of ACL injuries and those to the posterior cruciate ligament, posterolateral corner , posteromedial corner , and menisci, it is critical that the examiner perform provocative maneuvers to evaluate the integrity of these structures as well.
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Affiliation(s)
- David E Kantrowitz
- Department of Orthopedics, The Mount Sinai Hospital, 5 E 98th Street, 9th floor, New York, NY 10029, USA.
| | - Alexis Colvin
- Department of Orthopedics, The Mount Sinai Hospital, 5 E 98th Street, 9th floor, New York, NY 10029, USA
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Hesmerg MK, Oostenbroek MHW, van der List JP. Lever sign test shows high diagnostic accuracy for anterior cruciate ligament injuries: A systematic review and meta-analysis of 3299 observations. Knee 2024; 47:81-91. [PMID: 38310817 DOI: 10.1016/j.knee.2024.01.003] [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: 10/31/2023] [Revised: 12/05/2023] [Accepted: 01/18/2024] [Indexed: 02/06/2024]
Abstract
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.
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Affiliation(s)
- Mees K Hesmerg
- Centre for Orthopaedic Research Alkmaar (CORAL), Alkmaar, The Netherlands; Amsterdam UMC, Location University of Amsterdam, Department of Orthopaedic Surgery, Amsterdam, The Netherlands; Amsterdam Movement Sciences, Musculoskeletal Health, Amsterdam, The Netherlands.
| | - Maurits H W Oostenbroek
- Centre for Orthopaedic Research Alkmaar (CORAL), Alkmaar, The Netherlands; Northwest Clinics, Department of Orthopaedic Surgery, Alkmaar, The Netherlands
| | - Jelle P van der List
- Centre for Orthopaedic Research Alkmaar (CORAL), Alkmaar, The Netherlands; Northwest Clinics, Department of Orthopaedic Surgery, Alkmaar, The Netherlands; Atrium Health Wake Forest Baptist, Department of Orthopaedic Surgery and Rehabilitation, Winston Salem, NC, United States
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Hu S, Wang X, Wang Q, Feng W. Lever sign test for anterior cruciate ligament injuries: a diagnostic meta-analysis. J Orthop Surg Res 2024; 19:155. [PMID: 38429720 PMCID: PMC10905791 DOI: 10.1186/s13018-024-04635-w] [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: 12/03/2023] [Accepted: 02/21/2024] [Indexed: 03/03/2024] Open
Abstract
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.
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Affiliation(s)
- Shiqiang Hu
- Orthopaedics Department, Xiaolan People's Hospital of Zhongshan, Zhongshan, People's Republic of China
| | - Xiaoping Wang
- Orthopaedics Department, Xiaolan People's Hospital of Zhongshan, Zhongshan, People's Republic of China
| | - Qiyue Wang
- Sports Medicine Center, Department of Orthopaedics Surgery, First Affiliated Hospital of Shantou University Medical College, Shantou, People's Republic of China
| | - Weili Feng
- Orthopaedics Department, Xiaolan People's Hospital of Zhongshan, Zhongshan, People's Republic of China.
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Cavelti D, Grehn H, Luomajoki H. [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]. SPORTVERLETZUNG SPORTSCHADEN : ORGAN DER GESELLSCHAFT FUR ORTHOPADISCH-TRAUMATOLOGISCHE SPORTMEDIZIN 2023; 37:187-195. [PMID: 38048809 DOI: 10.1055/a-2153-1550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
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.
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Affiliation(s)
- David Cavelti
- Physiotherapy, Kantonsspital Graubunden, Chur, SWITZERLAND
| | | | - Hannu Luomajoki
- Gesundheit, Institut für Physiotherapie, Zürcher Hochschule fur Angewandte Wissenschaften, Winterthur, SWITZERLAND
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Dawod MS, Alswerki MN, Darabah AJ, Darabah YJ, Akel AY, Alisi MS. Clinical Reproducibility and Reliability of Lever Sign (Lelli's) Test for Acute ACL Tear Performed by Medical Students. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2023; 14:289-295. [PMID: 37012990 PMCID: PMC10066700 DOI: 10.2147/amep.s402496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/16/2023] [Indexed: 06/19/2023]
Abstract
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.
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Affiliation(s)
- Moh’d S Dawod
- Department of Orthopedic Surgery, Mu’tah School of Medicine, Mu’tah University, Al-karak, Jordan
| | | | - Asem J Darabah
- Department of Orthopedic Surgery, Mu’tah School of Medicine, Mu’tah University, Al-karak, Jordan
| | - Yazeed J Darabah
- Department of Orthopedic Surgery, Mu’tah School of Medicine, Mu’tah University, Al-karak, Jordan
| | - Alaa Y Akel
- Department of Orthopedic Surgery, Mu’tah School of Medicine, Mu’tah University, Al-karak, Jordan
| | - Mohammed S Alisi
- Department of Orthopedic Surgery, Jordan University Hospital, Amman, Jordan
- Faculty of Medicine, Islamic University of Gaza, Gaza, Palestine
- Ministry of Health, Gaza, Palestine
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Brophy RH, Silverman RM, Lowry KJ. American Academy of Orthopaedic Surgeons Clinical Practice Guideline Case Study: Management of Anterior Cruciate Ligament Injuries. J Am Acad Orthop Surg 2023; 31:538-548. [PMID: 36952667 DOI: 10.5435/jaaos-d-23-00088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/05/2023] [Indexed: 03/25/2023] Open
Abstract
Considering the frequency of anterior cruciate ligament (ACL) tears, optimal management of these injuries was the subject of a 2022 clinical practice guideline update from The American Academy of Orthopaedic Surgeons (AAOS) with input from representatives from the American Orthopaedic Society for Sports Medicine, the Pediatric Orthopaedic Society of North America, the American Orthopaedic Society for Sports Medicine, the American Medical Society for Sports Medicine, the American Academy of Physical Medicine and Rehabilitation, and the American College of Emergency Physicians. The eight recommendations and seven options to guide orthopaedic surgeons and other physicians managing patients with these anterior cruciate ligament injuries are based on the best current available evidence. The cases presented in this article are examples designed to demonstrate the clinical application of these guidelines.
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Affiliation(s)
- Robert H Brophy
- From the Washington University Orthopedics, Chesterfield, MO (Brophy), the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO (Silverman), and the Aspirus Rhinelander Hospital, Rhinelander, WI (Lowry)
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Nascimento BFD, Lima MBDR, Dias Júnior JM, Antunes Filho J, Campos TVDO, Mendes Júnior AF. Calculation of the Minimal Important Clinical Difference of the Lysholm and IKDC Scores After Anterior Cruciate Ligament Reconstruction. Rev Bras Ortop 2022; 58:79-84. [PMID: 36969791 PMCID: PMC10038720 DOI: 10.1055/s-0042-1756330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 06/26/2022] [Indexed: 03/26/2023] Open
Abstract
Objective
To calculate the minimal important clinical difference (MICD) value for the Lysholm and International Knee Documentation Committee (IKDC) scores in a sample of patients submitted to anterior cruciate ligament reconstruction.
Methods
Primary, observational, retrospective, analytical study of participants submitted to anterior cruciate ligament reconstruction from March 2019 to December 2020 by the same surgeon, with a minimum follow-up of 6 months, analysis of knee function in the pre- and postoperative period by the Lysholm and IKDC scores, and answer to an anchor question at 6 months postoperatively for the calculation of the MICD of each score.
Results
A total of 59 patients participated in the study, with a mean age of 27.1 ± 5.7 years old. In the comparison between pre- and postoperative scores of all groups, there was an increase in values with statistical significance after intervention. The MICD was 5.5 for the Lysholm score, and the MICD value for the IKDC score could not be determined.
Conclusion
For the Lysholm score, the calculation of the MICD value by the anchor question method in the sample evaluated was 5.5. It was not possible to determine the value of the MICD for the IKDC score.
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Affiliation(s)
- Bruno Fajardo do Nascimento
- Serviço de Ortopedia e Traumatologia, Hospital Universitário da Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
- Endereço para correspondência Bruno Fajardo do Nascimento, MD Grupo de joelho, Departamento de Ortopedia e Traumatologia, Universidade Federal de Juiz de foraRua Carlos Chagas, 71, São Mateus, Juiz de Fora, MG, 36025-010Brasil
| | - Mariana Bandeira da Rocha Lima
- Serviço de Ortopedia e Traumatologia, Hospital Universitário da Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
| | - Jair Moreira Dias Júnior
- Serviço de Ortopedia e Traumatologia, Hospital Universitário da Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
| | | | | | - Adriano Fernando Mendes Júnior
- Serviço de Ortopedia e Traumatologia, Hospital Universitário da Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
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