Lever Sign Research Articles

DIAGNOSTIC ACCURACY OF THE LEVER SIGN IN DETECTING ANTERIOR CRUCIATE LIGAMENT TEARS: A SYSTEMATIC REVIEW AND META-ANALYSIS

The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments in the knee. With the prevalence of ACL tears increasing, there is a growing need for clinical tests to rule in and rule out a suspected tear. A new clinical test for detecting ACL tears has been introduced with preliminary studies showing promising results. To systematically review and analyze information from the current literature on the diagnostic accuracy of the Lever Sign test for the use of diagnosing anterior cruciate ligament (ACL) injuries in a clinical setting. Systematic review and meta-analysis. A computerized search of PubMed, Cinahl, Scopus, and Proquest databases as well as a hand-search was completed on all available literature using keywords relating to the diagnostic accuracy of the Lever Sign Test. A quality assessment was performed on each article included in this review utilizing the Quality Assessment of Diagnostic Accuracy Studies (QUADAS). Eight articles were included, with only three studies exhibiting high quality, however the study samples were heterogenous. Included studies indicated that the Lever Sign test is both sensitive and specific in diagnosing ACL tears. Pooled sensitivity and specificity were 0.77 and 0.90, respectively. The negative likelihood ratio is 0.22 and the positive likelihood ratio is 6.60. The Lever Sign test is comparable to other clinical tests used in current practice to detect an ACL rupture. The pooled data from current available literature on the Lever Sign indicate that a positive or negative test should result in a moderate shift in post-test probability. This test may be used in addition to other tests to rule in and rule out the presence of an ACL rupture. 2a- Systematic Review of Level 2 diagnostic studies.

ACCURACY OF THE LEVER SIGN TO DIAGNOSE ANTERIOR CRUCIATE LIGAMENT TEAR: A SYSTEMATIC REVIEW WITH META-ANALYSIS

The Lever sign has gained recent notoriety for its purported anterior cruciate ligament (ACL) diagnostics and simplicity of performance. The purpose of this systematic review with meta-analysis is to summarize the diagnostic accuracy of the Lever sign for use during assessment of the knee for an ACL tear in subjects with suspected acute and chronic knee injury. Systematic review with meta-analysis. A computer-assisted literature search of MEDLINE, CINAHL, and EMBASE databases using keywords related to diagnostic accuracy of the knee joint. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for the search and reporting phases of the study. Quality assessment of bias and applicability was conducted using the Quality of Diagnostic Accuracy Studies (QUADAS). Mixed effects models were used to summarize accuracy. Eight articles, with only two demonstrating high quality, were included. Six of the articles were included in a meta-analysis. Diagnostic values, utilizing arthroscopy as a gold standard, were: pooled SN 0.55 (95% CI 0.22 to 0.84), pooled SP 0.89 (95% CI 0.44 to 0.99), positive likelihood ratio (+LR) 9.2 (95% CI 0.70 to 46.1), negative likelihood ratio (-LR) 0.58 (95% CI 0.18 to 1.28). Post-test probability with a positive finding (57% sampling prevalence) reached 92% (95% CI 83 to 97%). Post-test probability with a negative finding (57% sampling prevalence) reached 43% (95% CI 39 to 47%). Based on limited evidence of heterogeneous methodological quality, the Lever sign can moderately change post-test probability to rule in an ACL tear. These results should be interpreted cautiously due to a limited number of studies, with small sample sizes and study quality affecting test accuracy. Future investigation should be expanded to include additional high-quality studies examining diverse clinical contexts, as they become available, to enable a more comprehensive clinical examination of this test. 3aPROSPERO Registration # CRD42018084954.

The Validity Of Lever Sign Test For The Diagnosis Of ACL Injury

Background: Injury of the anterior cruciate ligament (ACL) is the most frequently seen ligamentous injury of the knee joint. Diagnosis is based on history, physical examination and MRI findings and a definitive diagnosis is confirmed with arthroscopy. Many tests are used for diagnosis of ACL with different sensitivity and specificity. Objectives: To evaluate lever sign test as a diagnostic tool for ACL injury compared the other 3 tests (anterior drawer, Lachman, and pivot shift test) when performed before anesthesia and under anesthesia. Patients and Methods: The study included 100 patients in the age of 18 to 45 years complaining of knee instability and confirmed as ACL injury by MRI. The 4 special tests for ACL (the Lachman, the anterior drawer, the pivot shift test and the lever sign test) were performed on the injured knee and the contralateral non-injured knee as a control both preanesthesia and under anesthesia. The results were compared to the arthroscopic findings. Results: Lever sign test sensitivity is 72% on examination before anesthesia and 80% on examination under anesthesia with specificity 92%. The most sensitive test Preanesthesia was the Lachman test 88% and postanesthesia was the pivot shift test 89%. The most specefic test was highest for the pivot-shift test 100%. Conclusion: Lever sign test is a simple test which can be routinely used in evaluation of ACL function in both acute and chronic knee injury. The test is weak diagnostic tool in partial ACL injury as it uses pure translational displacement as its assessment method and does not assess the rotational component.

Does the Lever Sign Test Have Added Value for Diagnosing Anterior Cruciate Ligament Ruptures?

Background:Diagnosing an anterior cruciate ligament (ACL) rupture based on a physical examination remains a challenge for both surgeons and physical therapists. The lever sign test was developed to overcome the practical limitations of other tests and to optimize diagnosis. An evaluation of the measurement properties of the lever sign test is needed to make adequate interpretations in practice.Purpose:To evaluate the reliability and diagnostic value of the lever sign test.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:A total of 94 patients were recruited between November 2014 and July 2016. Patients were included if they were at least 16 years old, suffered from knee trauma, and had indications for knee arthroscopic surgery. Lever sign, anterior drawer, Lachman, and pivot-shift test outcomes were examined by an orthopaedic/trauma surgeon and a physical therapist. A test-retest design was used to investigate interrater reliability. Moreover, the lever sign test outcomes, alone and in combination with the other diagnostic tests, were compared with arthroscopic results, which served as the gold standard for the test’s diagnostic value.Results:The lever sign test and pivot-shift test had kappa values exceeding 0.80 for interrater reliability. The kappa values for the anterior drawer test and Lachman test were 0.80 and 0.77, respectively. The lever sign test showed the highest specificity (100%) and the lowest sensitivity (39%) when compared with the other 3 tests. Moreover, its positive and negative predictive values were 100% and 65%, respectively, while an accuracy of 71% was calculated. Clustering the lever sign test parallel with the other 3 tests resulted in the highest accuracy of 91%.Conclusion:The lever sign test appears to have high interrater reliability and is the most specific test, showing a maximal positive predictive value. A positive lever sign test result indicates an ACL rupture. These results support the added value of the lever sign test for diagnosing ACL ruptures.

THE DIAGNOSTIC ACCURACY OF THE LEVER SIGN FOR DETECTING ANTERIOR CRUCIATE LIGAMENT INJURY.

An alternative physical examination procedure for evaluating the integrity of the anterior cruciate ligament (ACL) has been proposed in the literature but has not been validated in a broad population of patients with a symptomatic complaint of knee pain for its diagnostic value. To investigate the diagnostic accuracy of the Lever Sign to detect ACL tears and compare the results to Lachman testing in both supine and prone positions. Prospective, blinded, diagnostic accuracy study. Sixty-two consecutive patients with a complaint of knee pain were independently evaluated for the status of the ACL's integrity with the Lever Sign and the Lachman test in a prone and supine by a blinded examiner before any other diagnostic assessments were completed. Twenty-four of the 60 patients included in the analysis had a torn ACL resulting in a prevalence of 40%. The sensitivity of the Lever Sign, prone, and supine Lachman tests were 38, 83, and 67 % respectively and the specificity was 72, 89, and 97% resulting in positive likelihood ratios of 1.4, 7.5, and 24 and negative likelihood ratios of 0.86, 0.19, and 0.34 respectively. The positive predictive values were 47, 83, and 94% and the negative predictive values were 63, 89, and 81% respectively. The diagnostic odds ratios were 1.6, 40, and 70 with a number needed to diagnose of 10.3, 1.4, and 1.6 respectively. The results of this study suggest that Lever Sign, in isolation, does not accurately detect the status of the ACL. During the clinical examination, the Lever Sign should be used as an adjunct to the gold standard assessment technique of anterior tibial translation assessment as employed in the Lachman tests in either prone or supine position. 2.

Accuracy of the Lever Sign Test in the Diagnosis of Anterior Cruciate Ligament Injuries.

Background:The lever sign test is a new physical examination tool to diagnose anterior cruciate ligament (ACL) tears. Preliminary results suggest almost 100% sensitivity and specificity to diagnose acute and chronic complete ACL tears and clinically significant partial tears as compared with magnetic resonance imaging (MRI).Purpose:To assess the sensitivity and specificity of the lever sign test for the diagnosis of acute ACL injuries, as compared to MRI. We also aimed to determine the accuracy of the lever sign test compared with 3 other tests (anterior drawer, Lachman, and pivot shift) when performed by providers of various training levels, and with the patient awake or under anesthesia.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:We evaluated patients with a chief concern of acute (≤4 weeks) knee pain seen between October 2014 and January 2015, with a thorough history, physical examination, and standard radiographs. MRI was the reference standard; patients without an MRI evaluation were excluded. The 4 physical examination maneuvers were performed on each symptomatic knee during the initial clinic visit (for nonsurgical patients) or under anesthesia in the operating room (for surgical patients) by a randomly assigned undergraduate student, medical student, orthopaedic resident, or orthopaedic fellow. The senior author trained all staff to perform the lever sign test. Statistical analyses were performed.Results:Of 102 patients, 54 were surgical (28 female, 26 male), and 48 were nonsurgical (16 female, 32 male); the mean patient age was 23 years (range, 15-66 years). The overall accuracy of the lever sign test was 77% (63% sensitivity, 90% specificity); the accuracy was similar between patients under anesthesia and awake (77% vs 76%, respectively). There were no significant differences when comparing the sensitivity and specificity of the lever sign test with patients under anesthesia and awake (sensitivity: under anesthesia, 86%, and awake, 68% [P = .40]; specificity: under anesthesia, 85%, and awake, 96% [P = .17]). Furthermore, the accuracy of the lever sign test was similar when performed on female versus male patients (75% vs 79%, respectively) or when performed by undergraduate students and medical students compared with orthopaedic residents and fellows (84% vs 88%, respectively).Conclusion:Our study results challenge the exceptional sensitivity and specificity values (both 100%) of the lever sign test, as reported by the original author of the test.

Precise reevaluation of lever sign in patients with anterior cruciate ligament rupture

Precise reevaluation of lever sign in patients with anterior cruciate ligament rupture

The arthroscopical and radiological corelation of lever sign test for the diagnosis of anterior cruciate ligament rupture.

The aim of the current study was to evaluate the sensitivity of the lever sign test and the widely used basic tests of the Lachman, anterior drawer and pivot shift tests, both under anaesthesia and without anaesthesia, according to the gold standard diagnostic arthroscopic results in patients undergoing anterior cruciate ligament reconstruction. The study included 117 patients, diagnosed with ACL tear which was definitively determined during an arthroscopic surgical procedure applied. Before anaesthesia and while under anaesthesia, the Lachman, anterior drawer, pivot shift and lever sign tests were applied to all patients. Evaluation was made of MR images for each patient and documented. The patients comprised 96 males and 21 females, witha mean age of 25.8 ± 5.9 years (range, 17–45 years). Total tear was determined in 82 cases, anteromedial (AM) bundle in 14, posterolateral (PL) bundle in 13 and elongation in 8. Pre-anaesthesia positivity was found in lever sign at 94.2 %, Lachman at 80.5 %, pivot shift at 62.3 % and anterior drawer at 60.1 %. These rates were determined after anaesthesia as lever sign 98.4 %, Lachman 88.7 %, pivot shift 88.3 % and anterior drawer 84.2 %. The lever sign test can be easily applied clinically and it seems to have higher sensitivity than the Lachman test which is the basis of classic information, it should be included in routine clinical practice. In the light of the results of this study, further studies are required to review the accepted view that the Lachmann test is the most reliable test.