Value of clinical tests in diagnosing anterior cruciate ligament injuries: A systematic review and meta-analysis

Abstract

Objectives: This study compared 4 clinical tests with reference to magnetic resonance imaging and arthroscopic visualization to comprehensively evaluate their diagnostic value for anterior cruciate ligament injuries.

Methods: We systematically searched 10 electronic databases from January 1, 2010, to May 1, 2021. Two reviewers collected data in accordance with the Preferred Reporting Item for Systematic Reviews and Meta-Analyses 2020 guidelines. The quality of each study was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. A meta-analysis was performed using Meta-Disc version 1.4 and Stata SE version 15.0.

Results: Eighteen articles involving 2031 participants were included. The results of the meta-analysis showed that for the Lachman test, the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnosis odds ratio, area under the curve (AUC) of summary receiver operating characteristic (SROC), and Q* were 0.76 (95% CI, 0.73-0.78), 0.89 (95% CI, 0.87-0.91), 5.65 (95% CI, 4.05-7.86), 0.28 (95% CI, 0.23-0.36), 22.95 (95% CI, 14.34-36.72), 0.88, and 0.81, respectively. For the anterior drawer test, the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnosis odds ratio, AUC of SROC, and Q* were 0.64 (95% CI, 0.61-0.68), 0.87 (95% CI, 0.84-0.90), 3.57 (95% CI, 2.13-5.96), 0.44 (95% CI, 0.32-0.59), 8.77 (95% CI, 4.11-18.74), 0.85, and 0.78, respectively. For the pivot shift test, the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnosis odds ratio, AUC of SROC, and Q* were 0.59 (95% CI, 0.56-0.62), 0.97 (95% CI, 0.95-0.98), 13.99 (95% CI, 9.96-19.64), 0.44 (95% CI, 0.35-0.55), 29.46 (95% CI, 15.60-55.67), 0.98, and 0.94, respectively. For the lever sign test, the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnosis odds ratio, AUC of SROC, and Q* were 0.79 (95% CI, 0.75-0.83), 0.92 (95% CI, 0.87-0.95), 9.56 (95% CI, 2.76-33.17), 0.23 (95% CI, 0.12-0.46), 47.38 (95% CI, 8.68-258.70), 0.94, and 0.87, respectively.

Conclusions: Existing evidence shows that these clinical tests have high diagnostic efficacy for anterior cruciate ligament injuries, and that every test has its own advantages and disadvantages. However, the above results should be validated through additional studies, considering the limited quality and quantity of our sample.

Figure 1.

Flow diagram of the literature search and selection processes.

Figure 2.

Risk of bias and applicability concerns graph.

Figure 3.

Risk of bias and applicability concerns summary.

Figure 4.

Forest plot for pooled effect sizes of LT for the diagnosis of ACL injuries. The subgraph of (A–F) refers to Sen, Spe, +LR, −LR, DOR, AUC, and Q*, respectively. ACL = anterior cruciate ligament, AUC = area under the curve, DOR = diagnostic odds ratio, +LR = positive likelihood ratio, −LR = negative likelihood ratio, LT = Lachman test.

Figure 5.

The sensitivity analysis of LT. LT = Lachman test.

Figure 6.

Funnel plot of LT for the diagnosis of ACL injuries. ACL = anterior cruciate ligament, LT = Lachman test.

Figure 7.

Forest plot for pooled effect sizes of ADT for the diagnosis of ACL injuries. The subgraph of (A–F) refer to Sen, Spe, +LR, −LR, DOR, AUC, and Q*, respectively. ACL = anterior cruciate ligament, AUC = area under the curve, ADT = anterior drawer test, DOR = diagnostic odds ratio, +LR = positive likelihood ratio, −LR = negative likelihood ratio.

Figure 8.

The sensitivity analysis of ADT. ADT = anterior drawer test.

Figure 9.

Funnel plot of ADT for the diagnosis of ACL injuries. ACL = anterior cruciate ligament.

Figure 10.

Forest plot for pooled effect sizes of PST for the diagnosis of ACL injuries. The subgraph of (A–F) refers to Sen, Spe, +LR, −LR, DOR, AUC, and Q*, respectively. +LR = positive likelihood ratio, −LR = negative likelihood ratio, ACL = anterior cruciate ligament, AUC = area under the curve, DOR = diagnostic odds ratio, PST = pivot shift test.

Figure 11.

The sensitivity analysis of PST. PST = pivot shift test.

Figure 12.

Funnel plot of PST for the diagnosis of ACL injuries. ACL = anterior cruciate ligament, PST = pivot shift test.

Figure 13.

Forest plot for pooled effect sizes of LST for the diagnosis of ACL injuries. The subgraph of (A–F) refers to Sen, Spe, +LR, −LR, DOR, AUC, and Q*, respectively. +LR = positive likelihood ratio, −LR = negative likelihood ratio, ACL = anterior cruciate ligament, AUC = area under the curve, DOR = diagnostic odds ratio, LST = lever sign test.

Figure 14.

The sensitivity analysis of LST. LST = lever sign test.

Figure 15.

Funnel plot of LST for the diagnosis of ACL injuries. ACL = anterior cruciate ligament, LST = lever sign test.