Dataset Information

Towards improving the identification of anterior cruciate ligament tears in primary point-of-care settings.

ABSTRACT:

Background

Only a small proportion of anterior cruciate ligament (ACL) tears are diagnosed on initial healthcare consultation. Current clinical guidelines do not acknowledge that primary point-of-care practitioners rely more heavily on a clinical history than special clinical tests for diagnosis of an ACL tear. This research will assess the accuracy of combinations of patient-reported variables alone, and in combination with clinician-generated variables to identify an ACL tear as a preliminary step to designing a primary point-of-care clinical decision support tool.

Methods

Electronic medical records (EMRs) of individuals aged 15-45?years, with ICD-9 codes corresponding to a knee condition, and confirmed (ACL⁺) or denied (ACL^-) first-time ACL tear seen at a University-based Clinic between 2014 and 2016 were eligible for inclusion. Demographics, relevant diagnostic indicators and ACL status based on orthopaedic surgeon assessment and/or MRI reports were manually extracted. Descriptive statistics calculated for all variables by ACL status. Univariate between group comparisons, clinician surveys (n =?17), availability of data and univariable logistic regression (95%CI) were used to select variables for inclusion into multivariable logistic regression models that assessed the odds (95%CI) of an ACL-tear based on patient-reported variables alone (consistent with primary point-of-care practice), or in combination with clinician-generated variables. Model performance was assessed by accuracy, sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios (95%CI).

Results

Of 1512 potentially relevant EMRs, 725 were included. Participant median age was 26?years (range 15-45), 48% were female and 60% had an ACL tear. A combination of patient-reported (age, sport-related injury, immediate swelling, family history of ACL tear) and clinician-generated (Lachman test result) variables were superior for ACL tear diagnosis [accuracy; 0.95 (90,98), sensitivity; 0.97 (0.88,0.98), specificity; 0.95 (0.82,0.99)] compared to the patient-reported variables alone [accuracy; 84% (77,89), sensitivity; 0.60 (0.44,0.74), specificity; 0.95 (0.89,0.98)].

Conclusions

A high proportion of individuals without an ACL tear can be accurately identified by considering patient-reported age, injury setting, immediate swelling and family history of ACL tear. These findings directly inform the development of a clinical decision support tool to facilitate timely and accurate ACL tear diagnosis in primary care settings.

SUBMITTER: Whittaker JL

PROVIDER: S-EPMC7165371 | biostudies-literature | 2020 Apr

REPOSITORIES: biostudies-literature

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Publications

Towards improving the identification of anterior cruciate ligament tears in primary point-of-care settings.

Whittaker Jackie L JL Chan Michelle M Pan Bo B Hassan Imran I Defreitas Terry T Hui Catherine C Macedo Luciana L Otto David D

BMC musculoskeletal disorders 20200417 1

<h4>Background</h4>Only a small proportion of anterior cruciate ligament (ACL) tears are diagnosed on initial healthcare consultation. Current clinical guidelines do not acknowledge that primary point-of-care practitioners rely more heavily on a clinical history than special clinical tests for diagnosis of an ACL tear. This research will assess the accuracy of combinations of patient-reported variables alone, and in combination with clinician-generated variables to identify an ACL tear as a prel ...[more]

PMID: 32303217

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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.

Project description:PurposeTo evaluate the incidence of complete lateral meniscal posterior root tears (LMPRTs) repaired at revision as compared with primary anterior cruciate ligament (ACL) reconstruction (PACLR) and to determine whether other demographic or surgical characteristics were associated with LMPRTs needing repair.MethodsA chart review was performed to identify the PACLR and revision ACL reconstruction (RACLR) cohorts. Demographic and surgical characteristics were recorded. Cases with concurrent lateral meniscal posterior root repair were identified. Cases were classified as acute (<5 months) or chronic (>5 months) based on the time from reported injury to surgery. Tunnel malposition in revision cases was recorded if either tunnel or both tunnels were malpositioned on radiographs and magnetic resonance imaging.ResultsData from 167 cases, 140 PACLR and 27 RACLR cases, were included. The cohorts had similar demographic characteristics including age, sex, and lateral meniscal injury. The overall incidence of lateral meniscal root repair in ACL reconstruction patients was 12.6% (21 of 167 patients). The incidence of LMPRT repair was 7.1% (10 of 140 patients) in the PACLR cohort versus 40.7% (11 of 27 patients) in the RACLR cohort. The revision cohort was significantly more likely to have a chronic injury (66.7% [18 of 27 patients] vs 31.4% [44 of 140 patients]). The most significant predictor of concurrent lateral meniscal posterior root repair was RACLR versus PACLR for both univariate and multivariate logistic regression analyses (χ2 = 20.603; P < .0001; odds ratio, 13.887; 95% confidence interval, 1.531-125.993). Analysis of tunnel positions for the revision group revealed that PACLR tunnel malposition was a significant predictor of LMPRTs (χ2 = 4.91, P = .027).ConclusionsComplete LMPRTs warranting repair are encountered with a significantly greater frequency at RACLR as compared with PACLR. The overall incidence of LMPRT repair at RACLR is high. In this cohort, LMPRT repair in RACLR cases was associated with tunnel malposition of the PACLR.Level of evidenceLevel III, retrospective cohort study.

Dataset Information

Towards improving the identification of anterior cruciate ligament tears in primary point-of-care settings.

Background

Methods

Results

Conclusions

Publications

Towards improving the identification of anterior cruciate ligament tears in primary point-of-care settings.

Similar Datasets

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