Abstract
ObjectiveTo assess the diagnostic validity of clusters combining history elements and physical examination tests to diagnose partial or complete anterior cruciate ligament (ACL) tears.DesignProspective diagnostic study.SettingsOrthopaedic clinics (n = 2), family medicine clinics (n = 2) and community-dwelling.ParticipantsConsecutive patients with a knee complaint (n = 279) and consulting one of the participating orthopaedic surgeons (n = 3) or sport medicine physicians (n = 2).InterventionsNot applicable.Main outcome measuresHistory 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.ResultsForty-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).ConclusionDiagnostic clusters combining history elements and physical examination tests can support the differential diagnosis of ACL tears compared to various knee disorders.
Highlights
The anterior cruciate ligament (ACL) is a major stabilizing structure of the knee against excessive anterior translation and internal rotation of the tibia [1, 2]
This study assessed the diagnostic validity of clusters combining history elements and physical examination tests to diagnose or exclude partial or complete ACL tears compared to other knee disorders
We first observed that when individually performed, the Lachman and the pivot shift tests reached substantial positive LR (LR+>10) to diagnose and moderate negative LR (LR-
Summary
The anterior cruciate ligament (ACL) is a major stabilizing structure of the knee against excessive anterior translation and internal rotation of the tibia [1, 2]. The overall incidence rate in the general population varies between 30 to 80 per 100000 persons-years [3,4,5]. This injury is common in younger individuals as it occurs approximately 70% of the time as a result of a trauma in a sporting activity requiring pivot such as football, soccer, basketball or alpine skiing [1, 5,6,7]. In the United States, this translate to about 250 000 ACL tears annually [7] Of these individuals, 50 to 75% will opt for an ACL reconstruction surgery which incurs costs of up to two billion dollars [1, 3, 5, 8]
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