The diagnostic accuracy of clinical tests for anterior cruciate ligament tears are comparable but the Lachman test has been previously overestimated: a systematic review and meta-analysis

Pawel A Sokal, Richard Norris, Thomas W Maddox, Rachel A Oldershaw, Pawel A Sokal, Richard Norris, Thomas W Maddox, Rachel A Oldershaw

Abstract

Purpose: The diagnostic accuracy of clinical tests for anterior cruciate ligament injury has been reported in previous systematic reviews. Numerous studies in these reviews include subjects with additional knee ligament injury, which could affect the sensitivity of the tests. Meta-analyses have also been performed using methods that do not account for the non-independence of sensitivity and specificity, potentially overestimating diagnostic accuracy. The aim of this study was to report the diagnostic accuracy of clinical tests for anterior cruciate ligament tears (partial and complete) without concomitant knee ligament injury.

Methods: A systematic review with meta-analysis was performed according to the PRISMA guidelines. Meta-analyses included studies reporting the specificity and/or sensitivity of tests with or without concomitant meniscal injury. Where possible, pooled diagnostic estimates were calculated with bivariate random-effects modelling to determine the most accurate effect sizes. Diagnostic accuracy values are presented for the anterior drawer, Lachman, Lever sign and pivot shift tests overall and in acute or post-acute presentations.

Results: Pooled estimates using a bivariate model for overall sensitivity and specificity respectively were as follows: anterior drawer test 83% [95% CI, 77-88] and 85% [95% CI, 64-95]; Lachman test 81% [95% CI, 73-87] and 85% [95% CI, 73-92]; pivot shift test 55% [95% CI, 47-62] and 94% [95% CI, 88-97]; Lever sign test 83% [95% CI, 68-92] and 91% [95% CI, 83-95]. For specific presentations, the sensitivity and specificity of the Lachman test, respectively, were: complete tears 68% [95% CI, 54-79] and 79% [95% CI, 51-93]; post-acute injuries 70% [95% CI, 57-80] and 77% [95% CI, 53-91].

Conclusions: The pivot shift and Lever sign were the best tests overall for ruling in or ruling out an anterior cruciate ligament tear, respectively. The diagnostic accuracy of the Lachman test, particularly in post-acute presentations and for complete tears, is lower than previously reported. Further research is required to establish more accurate estimates for the Lachman test in acute presentations and partial ligament tears using bivariate analysis.

Level of evidence: III.

Keywords: ACL; ACL tear; Anterior drawer; Clinical diagnostic tests; Knee injuries; Lachman; Lever sign; Meta-analysis; Pivot shift; Sporting injuries.

Conflict of interest statement

The authors declare no conflicts of interest.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
PRISMA flow diagram showing selection process outcome. Retrieved studies were systematically excluded against the inclusion and exclusion criteria. Arrows pointing downwards indicate the process of identifying relevant articles. Arrows pointing to the right show articles excluded from the review
Fig. 2
Fig. 2
Fagan’s nomogram of shift in pre-test to post-test probability of clinical tests. Fagan’s nomograms illustrating the shift in pre-test to post-test probability for the a anterior drawer, b Lachman, c Lever sign and d Pivot shift tests. The pre-test probability of acute ACL tear is shown on the left vertical axis (36%). The post-test probability is shown on the right vertical axis. The middle vertical axis shows value of likelihood ratio. The blue line represents a change in ACL tear probability when the test is positive. The red line indicates a change in ACL injury probability when test is negative

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