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Clinical diagnosis of partial or complete anterior cruciate ligament tears using patients' history elements and physical examination tests.

ABSTRACT: OBJECTIVE:To assess the diagnostic validity of clusters combining history elements and physical examination tests to diagnose partial or complete anterior cruciate ligament (ACL) tears. DESIGN:Prospective diagnostic study. SETTINGS:Orthopaedic clinics (n = 2), family medicine clinics (n = 2) and community-dwelling. PARTICIPANTS:Consecutive patients with a knee complaint (n = 279) and consulting one of the participating orthopaedic surgeons (n = 3) or sport medicine physicians (n = 2). INTERVENTIONS:Not applicable. MAIN OUTCOME MEASURES:History 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. RESULTS:Forty-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). CONCLUSION:Diagnostic clusters combining history elements and physical examination tests can support the differential diagnosis of ACL tears compared to various knee disorders.

SUBMITTER: Decary S

PROVIDER: S-EPMC5997333 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Clinical diagnosis of partial or complete anterior cruciate ligament tears using patients' history elements and physical examination tests.

Décary Simon S Fallaha Michel M Belzile Sylvain S Martel-Pelletier Johanne J Pelletier Jean-Pierre JP Feldman Debbie D Sylvestre Marie-Pierre MP Vendittoli Pascal-André PA Desmeules François F

PloS one 20180612 6

<h4>Objective</h4>To assess the diagnostic validity of clusters combining history elements and physical examination tests to diagnose partial or complete anterior cruciate ligament (ACL) tears.<h4>Design</h4>Prospective diagnostic study.<h4>Settings</h4>Orthopaedic clinics (n = 2), family medicine clinics (n = 2) and community-dwelling.<h4>Participants</h4>Consecutive patients with a knee complaint (n = 279) and consulting one of the participating orthopaedic surgeons (n = 3) or sport medicine p ...[more]

PMID: 29894492

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Project description:ObjectivesPartial ACL tears are increasingly recognized in young active patients. They can evolve into complete tears. Controversy exists regarding the need to spare intact ACL bundle as it has its advantages considering biomechanical strength, blood supply and proprioception. The current study determined the challenges in partial ACL tear management and assessed the functional outcomes.MethodsTwenty consecutive patients with partial ACL tears were studied. Inclusion criteria were: age 16-45yrs and patients operated for partial ACL tear. Exclusion criteria were: combined ACL-PCL injuries, associated collateral injuries, complete ACL tear, chondral defect or bony malalignment and patients with radiographic signs of arthritis. 'Partial' tear was defined as continuous fibers from native tibial ACL footprint to native femoral ACL footprint in arthroscopy. Clinical and radiological assessment was done to evaluate anteromedial(AM) or posterolateral(PL) bundle tears. We used the term "ACL-augmentation" without disturbing the intact bundle or preserving the intact fibers as much as possible. Functional scoring was done using Lysholm score. Standard post-operative protocols were followed. Statistical analysis was done using SPSS software.ResultsMean age of patients was 31.2 years. Physically active age group (<30yrs) included 62.5% patients. Males were 87.5%. Pain and instability were the presenting complaints in 75% and 70% respectively. Average duration of presentation since injury was 4.2 months. Sports activities were the most common mode of injury (45%) followed by road traffic accidents (37.5%). Anterior drawer test was positive in 40%, pivot shift in 35% and Lachman test was positive in 65%. On arthroscopy, 65% had AM bundle tears and 35% had PL bundle tears. The intact bundle was found lax in 13% cases. Associated meniscal tear was present in 28% patients. Stiff knee was the most common post-operative complaint. Preoperative Lysholm knee score of 74.5 improved to 87.7 at 12months (p < 0.001). Around 97.5% of the patients reported outcomes as good and fair.ConclusionThe treatment strategy needs to be individualized. The ACL augmentation needs more systematic and accurate placement of portals while sparing the intact ACL fibers. For AM bundle, tibial tunnel entry point is about 1-2 cm medial to tibial tuberosity. For PL bundle, it is about 3-4 cm medial to tibial tuberosity to protect the AM bundle. Long term studies with greater number of subjects are required.

Project description:BackgroundAn anterior cruciate ligament (ACL) tear is a common knee injury, particularly among young and active individuals. Little is known, however, about the societal impacts of ACL tears, which could be large given the typical patient age and increased lifetime risk of knee osteoarthritis. This study evaluates the cost-effectiveness of ACL reconstruction compared with structured rehabilitation only.MethodsA cost-utility analysis of ACL reconstruction compared with structured rehabilitation only was conducted with use of a Markov decision model over two time horizons: the short to intermediate term (six years), on the basis of Level-I evidence derived from the KANON Study and the Multicenter Orthopaedic Outcomes Network (MOON) database; and the lifetime, on the basis of a comprehensive literature review. Utilities were assessed with use of the SF-6D. Costs (in 2012 U.S. dollars) were estimated from the societal perspective and included the effects of the ACL tear on work status, earnings, and disability. Effectiveness was expressed as quality-adjusted life years (QALYs) gained.ResultsIn the short to intermediate term, ACL reconstruction was both less costly (a cost reduction of $4503) and more effective (a QALY gain of 0.18) compared with rehabilitation. In the long term, the mean lifetime cost to society for a typical patient undergoing ACL reconstruction was $38,121 compared with $88,538 for rehabilitation. ACL reconstruction resulted in a mean incremental cost savings of $50,417 while providing an incremental QALY gain of 0.72 compared with rehabilitation. Effectiveness gains were driven by the higher probability of an unstable knee and associated lower utility in the rehabilitation group. Results were most sensitive to the rate of knee instability after initial rehabilitation.ConclusionsACL reconstruction is the preferred cost-effective treatment strategy for ACL tears and yields reduced societal costs relative to rehabilitation once indirect cost factors, such as work status and earnings, are considered. The cost of an ACL tear over the lifetime of a patient is substantial, and resources should be directed to developing innovations for injury prevention and for altering the natural history of an ACL injury.

Dataset Information

Clinical diagnosis of partial or complete anterior cruciate ligament tears using patients' history elements and physical examination tests.

Publications

Clinical diagnosis of partial or complete anterior cruciate ligament tears using patients' history elements and physical examination tests.

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