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Diagnosis klinis dari anterior

ligamentum cruciatum Pecahnya:


A Meta-analisis
Anne Benjaminse, PT 1

Alli Gokeler, PT 2

Cees P. van der Schans, PT, PhD 3

Desain studi: Meta-analisis. strategi pencegahan dan metode pengobatan


tujuan: Untuk menentukan akurasi uji klinis untuk menilai anterior cruciate ligament (ACL) pecah. yang optimal memiliki kesehatan yang luas
dan
implikasi ekonomis. 24

Latar Belakang: Ligamen cruciatum, dan terutama ACL, antara struktur yang paling umum
cedera lutut. Mengingat meningkatnya prevalensi cedera, ada tidak diragukan lagi kebutuhan

W
LITERATUREREVIE
ACL pecah dapat meninggalkan
yang berkembang untuk pengambilan keputusan klinis dari penyedia layanan kesehatan. Kami
Ulasan literatur untuk menganalisis akurasi diagnostik dari pemeriksaan klinis untuk menilai
pasien dengan ketidakstabilan sendi
ACL pecah. lutut selama kegiatan fungsional.

Metode dan Ukuran: MEDLINE (1966-April 2005), EMBASE (1989 sampai April 2005), Dengan tidak adanya ACL tugas
dan CINAHL (1982 sampai April 2005) pencarian dilakukan. Juga referensi daftar menahan diri jatuh pada struktur
studi termasuk ditinjau. Studi yang dipilih untuk ekstraksi data adalah mereka yang ligamen sekunder. Jadi, dengan waktu,
ditujukan akurasi minimal 1 tes diagnostik fisik untuk ACL pecah dan pembatasan sekunder lutut
membandingkan kinerja pemeriksaan klinis lutut dengan standar referensi, seperti ACLdeficient mungkin juga menjadi
Artroskopi, arthrotomy, atau MRI. Mencari terbatas pada bahasa Inggris, Jerman,
longgar atau terluka. bedah
dan bahasa Belanda.
rekonstruksi ACL adalah pengobatan
pilihan pada pasien aktif menyajikan
hasil: Dua puluh delapan studi yang menilai akurasi uji klinis untuk mendiagnosa ACL pecah memenuhi kriteria
inklusi. Hasil dengan ketidakstabilan. 11 Efek jangka
penelitian itu, bagaimanapun, heterogen. Tes Lachman adalah tes yang paling valid untuk panjang dari ketidakstabilan dapat
menentukan air mata ACL,
meningkatkan kemungkinan timbulnya
menunjukkan sensitivitas dikumpulkan dari 85% (95% confidence interval [CI], 83-87) dan spesifisitas
For personal use

dikumpulkan dari 94% awal osteoarthritis. 51 Berdasarkan


(95% CI, 92-95). Tes poros pergeseran sangat spesifik, yaitu 98% (95% CI, 96-99), tetapi memiliki sensitivitas literatur meta-analisis ini, rekonstruksi
only.

miskin 24%
ACL tampaknya unggul pengobatan
(95% CI, 21-27). Tes anterior laci menunjukkan sensitivitas yang baik dan spesifisitas dalam kondisi kronis,
masing-masing konservatif untuk menyelesaikan
92% (95% CI, 88-95) dan 91% (95% CI, 87-94), tetapi tidak dalam kondisi akut. ketidakstabilan sendi objektif dan
subjektif dan membantu kembali ke
Kesimpulan: Dalam kasus yang dicurigai cedera ACL dianjurkan untuk melakukan tes tingkat preinjury olahraga. 29

Lachman. Karena tes poros pergeseran sangat spesifik baik dalam akut serta dalam kondisi
kronis, dianjurkan untuk melakukan tes poros pergeseran juga. J Orthop Olahraga Phys Ther
2006; 36 (5): 267-
288. doi: 10,2519 / jospt.2006.2011
08/29/1

Kata Kunci: akurasi, anterior ligamen, pemeriksaan, lutut


9.

bedah rekonstruksi. Dengan biaya diperkirakan


120.188.74.12
3 on

D
untuk cedera ini hampir satu miliar dolar per
288.

tahun, mengidentifikasi faktor risiko dan


-

cedera pada sendi lutut, 18,50,68,72 dengan peningkatan prevalensi mengembangkan


selama kegiatan
olahraga. 47 Misalnya, menurut Griffin et al, 24 diperkirakan 80 000
Therapist fisik (pada saat penelitian), Departemen Terapi
air mata ACL 1

fisik, Medisch Centrum Zuid, Groningen, Belanda; Peneliti


terjadi setiap tahun di Amerika Serikat, dengan 50 000
junior (pada saat penelitian), Hanze Universitas Groningen,
membutuhkan
Pusat Penelitian dan Pengembangan Pelayanan Kesehatan dan
Amage ke anterior ligamen (ACL) adalah utama Keperawatan, Groningen, Belanda.
2
watan, Hanze Universitas Groningen, Pusat Penelitian dan Pengembangan Pelayanan Kesehatan dan Keperawatan,
Olahrag
Groningen, Belanda.
a Dari perspektif ini, adalah sangat
Physical Alamat korespondensi untuk Cees P. van der Schans, Hanze Universitas Groningen, Pusat Penelitian dan
Therapis Pengembangan Pelayanan Kesehatan dan Keperawatan, Eyssoniusplein 18, 9714 CE Groningen, Belanda. E-mail: penting untuk melakukan tes yang
t, cpvan.der.schans@pl.hanze.nl paling akurat yang tersedia untuk
Peneliti,
Universit mendiagnosis pecah ACL, terutama
y
untuk terapis fisik yang berlatih
Medical
Center
Groning
en, di sebuah olahraga dan
Pusat
Pengaturan ortopedi tanpa rujukan
Rehabilit
asi oleh dokter. Mereka sangat
Groning
en, bergantung pada uji klinis dan karena
Belanda. itu harus mampu untuk menyaring
cedera ACL untuk membuat keputusan
3
pengobatan yang tepat dan membuat
Profes
rujukan untuk pencitraan lebih lanjut
or di

Peraw
dan diagnosis dan operasi mungkin. 22

atan

Keseh

atan
Tiga tes umum diterapkan dalam
dan

Kepera
praktek klinis untuk menentukan

Journal of Orthopaedic & Sports Terapi Fisik 267

tes positif, menunjukkan gangguan ACL. Seperti dijelaskan


Potensi studi diidentifikasi dan disaring
oleh IKDC 2000, 2 keparahan dinilai sebagai normal (-1 sampai
untuk pengambilan (N =
2 mm), hampir normal (3 sampai 5 mm), tidak normal (6
7143)
sampai 10 mm), atau sangat abnormal (10

mm), berdasarkan jumlah terjemahan tibialis lebih besar


di sisi terluka dibandingkan dengan lutut kontralateral
Studi dikeluarkan karena dianggap tidak
terluka.
berpotensi
relevan (n = 7095)
Tes poros pergeseran dilakukan dengan pasien terlentang.
Kaki diperpanjang dijemput di pergelangan kaki dengan
tangan ipsilateral pemeriksa. tangan ini secara internal
berputar lutut dan flexes lutut dari ekstensi penuh, sambil
teks lengkap dari studi diambil untuk
menerapkan valgus stres dengan tangan kontralateral pada
evaluasi yang lebih rinci (n = 48) sisi lateral tibia proksimal. Penurunan tiba-tiba dari anterior
subluksasi tibialis dataran tinggi lateral yang disebabkan
oleh saluran iliotibial menunjukkan tes poros pergeseran
positif. 23 The IKDC 2000 lutut nilai formulir pemeriksaan tes
pergeseran poros sebagai sama, meluncur (+), bunyi (++),
studi tidak disertakan dengan
atau bruto (+++). 2

alasan (n = 21)

Karena data mengenai validitas tes diagnostik klinis untuk


pecah ACL yang heterogen, sulit untuk menyimpulkan mana
tes, atau yang kombinasi tes, yang paling tepat untuk
diagnosis dicurigai ACL pecah. Tujuan dari meta-analisis
adalah untuk mengevaluasi akurasi diagnostik dari laci
anterior, Lachman, dan tes poros shift.

Studi termasuk di meta


120.188.74.123 on 08/29/19. For personal

analisis, termasuk ref 55 (n =


28)
use only.

GAMBAR 1. Mengalir diagram strategi pencarian.

cedera ACL adalah laci anterior, yang Lachman, dan tes poros
shift. Untuk tes laci anterior, pasien terlentang dengan pinggul
tertekuk sampai 45 °, lutut tertekuk sampai 90 °, dan kaki
288.
-
bagian bawah diarahkan ke tibia proksimal dan hakim jumlah terjemahan
di rotasi tibialis. Menurut Komite Dokumentasi Lutut Internasional
netral. (IKDC 2000), 2 tes anterior laci dinilai sebagai normal (0-2
pemeriksa mm), hampir normal (3 sampai 5 mm), tidak normal (6 sampai
menstabilkan 10 mm), atau sangat abnormal ( 10 mm), berdasarkan jumlah
METODE
kaki pasien terjemahan tibialis lebih besar di sisi terluka dibandingkan
dengan dengan lutut kontralateral terluka. Peningkatan perpindahan Sastra Pencarian
pahanya dan tibialis anterior di sisi ke sisi perbandingan adalah indikasi
menempatka dari sebuah air mata ACL. Kami melakukan pencarian literatur terkomputerisasi untuk
n kedua mengambil artikel yang berkaitan dengan pemeriksaan klinis
tangan di pasien yang diduga cedera ligamen lutut. Kami melakukan 3
belakang pencarian independen dalam MEDLINE (1966-April 2005),
tibia EMBASE (1989 sampai April 2005), dan CINAHL (1982 sampai
proksimal April 2005). Hasil dari 3 pencarian tersebut digabungkan dan

dengan ibu duplikat telah dihapus. Selanjutnya, penelitian yang diperoleh

jari di melalui metode lain yang juga dianggap (misalnya, melalui

dataran kontak pribadi dan skrining referensi yang dikutip dalam

tinggi tibialis. artikel diambil sesuai). Strategi pencarian ditunjukkan pada

pemeriksa Gambar 1 dan operasional didefinisikan dalam Tabel 1.

berlaku
kekuatan
anterior

Seleksi Sastra
www.jospt.org J Orthop
Downloaded from

Sports Phys Ther

Setiap kutipan (judul dan abstrak) awalnya diidentifikasi


Tes Lachman dilakukan dengan pasien berbaring melalui strategi pencarian ditinjau oleh penulis pertama (AB)
terlentang dan dengan terlibat ekstremitas di sisi untuk potensi relevansi, seperti yang ditunjukkan pada
pemeriksa. femur distabilkan dengan 1 tangan, dengan Gambar 1. makalah lengkap kutipan diidentifikasi sebagai
sendi lutut pasien di 20 ° sampai 30 ° dari fleksi. tangan mungkin memenuhi syarat untuk dimasukkan diperoleh dan
pemeriksa lainnya diterapkan untuk aspek posterior tibia mandiri Ulasan untuk inklusi akhir (AB,
proksimal. Kekuatan anterior diarahkan diterapkan untuk
menggantikan tibia. Peningkatan terjemahan tibialis AG, dan CS). persyaratan minimal untuk dimasukkan adalah
anterior dengan titik akhir yang lembut dibandingkan sebagai berikut: (1) in vivo, studi manusia; (2) data yang
dengan sisi lain merupakan dilaporkan pada keakuratan minimal 1 tes diagnostik fisik
untuk ACL pecah; (3) arthroscopy,

268 J Orthop Olahraga Phys Ther • Volume 36 • Nomor 5 • Mei 2006


TABEL 1. Operasionalisasi strategi pencarian.

MEDLINE EMBASE (1989 CINAHL (1982


Jumlah (1966-April 2005) sampai April 2005) sampai April 2005)

1 '' Cedera lutut '' [MESH] meledak '' lutut cruciatum ligamen- '' / semua meledak '' cedera lutut '' / semua subpos
subpos + Semua subpos usia

2 '' Ligamen, artikular '' [MESH] meledak '' lutut ligamen cedera '' / semua meledak '' ligamen '' / semua subpos + se
subpos subpos usia

3 '' Diagnos * '' [TI, AB] meledak '' lutut cedera '' / semua subpos meledak '' ligamen-luka '' / semua sub
judul + semua subpos usia

4 '' Diagnosis '' [MESH] meledak '' anterior cruciate--ligament- pecah '' / meledak '' ligamen-artikular '' / semua su
semua subpos + semua subpos usia

5 '' Diagnosis '' [subpos] '' Diagnos * '' di ti, ab '' Diagnos * '' di ti, ab

6 '' Sensitiv * '' [TI, AB] meledak '' diagnosis '' / semua subpos meledak '' diagnosis '' / semua subpos + sem
subpos usia

7 '' Spesifik * '' [TI, AB] '' Sensitiv * '' di ti, ab '' Sensitiv * '' di ti, ab

8 '' Sensitivitas dan spesifisitas '' [MESH] '' Spesifik * '' di ti, ab '' Spesifik * '' di ti, ab

9 # 1 DAN # 2 DAN (# 3 OR # 4 OR # 5 OR # 6 meledak '' sensitivitas-dan-kekhususan '' / semua meledak '' sensitivitas-dan-kekhususan '' / se
OR # 7 OR # 8) subpos subpos + semua subpos usia

10 (# 1 OR # 2 OR # 3 OR # 4) DAN (# 5 OR # 6 (# 1) DAN (# 2 OR # 3 OR # 4) DAN (# 5 OR #


OR # 7 OR # 8 OR # 9) OR # 7 OR # 8 OR # 9)

R
LITE
Bila mungkin, data disarikan dari setiap artikel oleh
arthrotomy, atau magnetic resonance imaging (MRI) P
penulis pertama (AB) untuk memungkinkan perhitungan
digunakan sebagai standar emas untuk mengukur e
sensitivitas dan spesifisitas masing-masing fisik
keakuratan pemeriksaan fisik; (4) kemungkinan m
membangun tabel 2 × 2 menentukan nilai-nilai yang benar e
dan positif palsu dan benar dan negatif palsu; dan (5) ri
ditulis dalam bahasa Inggris, Jerman, atau Belanda.
k
s
a

Penilaian validitas dan Studi Karakteristik a


n
120.188.74.123 on 08/29/19. For personal

t
Sebuah standar penilaian kualitas metodologi mengenai
e
validitas studi dan penerapan hasil diadaptasi dari
Cochrane Metode Grup 1 dan diterapkan oleh 2 penulis (AB m
use only.

dan AG) untuk setiap studi disertakan. Mereka dinilai u

secara independen metode pengumpulan data, pemilihan a

pasien, menyilaukan, dan pencegahan bias verifikasi (yaitu, n


ketika hasil tes diagnostik mempengaruhi apakah prosedur .
standar emas digunakan untuk memverifikasi hasil tes), B
288.
-

desain penelitian, dan deskripsi uji indeks dan referensi e


standar. pertanyaan khusus digunakan untuk mengevaluasi ri
kriteria ini disajikan dalam Lampiran. Jawaban untuk k
pertanyaan ini disajikan pada Tabel 2. pengulas u
menyepakati jawaban atas sebagian besar pertanyaan- t
pertanyaan ini. Ketidaksepakatan diselesaikan melalui n
konsensus dengan bantuan resensi ketiga (CS). y
a,
d
a
t
a
s
e
Abstraksi data dan Kuantitatif Sintesis Data
c
a
r
a tabel. Kami tidak menghitung jumlah pasien termasuk;

W
ATUREREVIE
indep sebaliknya, kita membuat pilihan metodologis untuk
enden mempertimbangkan jumlah lutut dengan ACL pecah.
oleh Dalam evaluasi tes diagnostik, setiap studi individu
sebua dirangkum oleh sepasang statistik, sensitivitas dan
h spesifisitas, yang mengukur akurasi tes ini. Kemudian,
resen indeks akurasi tes secara keseluruhan dihitung sebagai
si rata-rata tertimbang dari ringkasan statistik, di mana
kedua berat masing-masing studi adalah ukuran sampel yang.
(CS). MetaDiSc menggunakan metode yang paling mudah untuk
Analis kolam sensitivitas dan spesifitas. sensitivitas menggenang
is dihitung sebagai jumlah positif sejati di semua studi,
statis dibagi dengan jumlah mata pelajaran di semua studi;
tik
dilaku
kan
denga
n
Meta-
disc,
Versi Hal ini setara dengan mengatakan bahwa metode
on mendekati metode penyatuan inverse-varians (yaitu,
1.0.9, bobot setiap studi sesuai dengan ukuran sampel yang). 75

dari
Untuk sensitivitas dan spesifisitas, metode pooling adalah
Zamo
model fixed-efek. Untuk positif (LR +), kemungkinan rasio
ra et
negatif (LR), dan diagnostik odds ratio (DOR), metode
al, 75
standar yang digunakan adalah model randomeffect. Uji
setela
chi-square telah disediakan untuk menilai homogenitas
h
sensitivitas dan spesifitas dari studi karena keduanya
memb
langkah-langkah yang proporsi sederhana. 16 Kami
angun
menghitung LR + dan LR, yang menggambarkan sifat
2×2
diskriminatif posi-

J Orthop Olahraga Phys Ther • Volume 36 • Nomor 5 • Mei 2006 269


MEJA 2. kualitas metodologis dari 28 studi.

Kriteria Validitas pendidikan


*

Referensi A1 A2 A3 A4 A5 A6 B1 B2 B3 B4 B5 C1 C2 C3 C4

Anderson et al, 1989 AS / AT b b d Sebuah c b Sebuah Sebuah b Sebuah Sebuah Sebuah b b


Boeree et al, 1991 MRI c e c Sebuah b b Sebuah Sebuah b b b b c c
Bomberg et al, 1990 SEBAGAI c b Sebuah Sebuah Sebuah c Sebuah d 1 Sebuah b b c c
Braunstein, 1982 DI b e e Sebuah c c c d b b Sebuah b b c

Cooperman et al, 1990 AS / AT b e f Sebuah b d b Sebuah 1 Sebuah Sebuah Sebuah Sebuah c


Dahlstedt et al, 1989 SEBAGAI c c c Sebuah c b b d b Sebuah Sebuah b b b
DeHaven, 1980 SEBAGAI c b Sebuah Sebuah Sebuah c Sebuah b 1 b b b b c
Donaldson et al, 1985 DI c b d b c b Sebuah d 2 Sebuah b Sebuah c b
Hardaker et al, 1990 SEBAGAI c b c c b c Sebuah d 2 b Sebuah b b c

Harilainen et al, 1987 AS / AT b b e Sebuah b b c d 2 Sebuah † Sebuah b b Sebuah


Hughston et al, 1976 DI c b c Sebuah c c Sebuah Sebuah b Sebuah Sebuah Sebuah c b

Jonnson et al, 1982 AS / AT b b c c c c Sebuah d b b b Sebuah † c b


Katz et al, 1986 SEBAGAI c b c b b b Sebuah d b Sebuah Sebuah Sebuah c c
Kim et al, 1995 SEBAGAI c b d b c c Sebuah d 2 Sebuah b Sebuah b b
Learmonth et al, 1991 SEBAGAI b b d Sebuah Sebuah b Sebuah c Sebuah b b b c c
Lee et al, 1988 MRI c Sebuah e Sebuah c b c d b b b Sebuah b b
Lucie et al, 1984 AS / AT Sebuah b d Sebuah Sebuah d Sebuah Sebuah Sebuah b b b b b
Liu et al, 1995 SEBAGAI c b d b c c c d b Sebuah b Sebuah ‡ b b

Mitsou et al, 1988 AS / AT b c c b c b Sebuah d b b b Sebuah b b


Noyes et al, 1980 SEBAGAI c b Sebuah Sebuah c c Sebuah Sebuah Sebuah Sebuah Sebuah Sebuah b b
Otter et al, 1994 SEBAGAI c Sebuah c Sebuah c b c d Sebuah b b b Sebuah b
Rubinstein et al, 1994 SEBAGAI c b d Sebuah b b b d Sebuah Sebuah b Sebuah Sebuah c

Sandberg et al, 1986 AS / AT b b e b Sebuah b Sebuah Sebuah Sebuah Sebuah b b b c


Schwarz et al, 1997 SEBAGAI c b c Sebuah b b Sebuah Sebuah b b b b b Sebuah
Steinbruck et al, 1988 SEBAGAI c Sebuah b c Sebuah b b Sebuah b b Sebuah b b b
Tonino et al, 1986 SEBAGAI c b c Sebuah c b Sebuah Sebuah Sebuah b b b b b
Torg et al, 1976 DI c b c b Sebuah c Sebuah Sebuah 1 b Sebuah Sebuah † b c
Warren et al, 1978 DI c b f b Sebuah c Sebuah Sebuah b b b b b c

Singkatan: AS, Artroskopi; AT, arthrotomy; MRI, magnetic resonance imaging.


* af, lihat daftar kriteria (Lampiran) untuk penjelasan; 1, hanya kriteria inklusi; 2, hanya kriteria eksklusi.
† Hanya tes Lachman.
‡ Hanya anterior laci dan uji Lachman.

tive dan hasil tes negatif, masing-masing. 4 Jadi, rasio HASIL


kemungkinan menggabungkan kedua sensitivitas dan
120.188.74.123 on 08/29/19. For personal

spesifisitas tes dan memberikan perkiraan langsung berapa Kualitas metodologis dan Karakteristik Studi
banyak hasil tes akan mengubah kemungkinan memiliki air
mata ACL. The DOR, di mana sensitivitas dan spesifisitas Pencarian di MEDLINE, EMBASE, dan CINAHL
use only.

dievaluasi secara keseluruhan, mengungkapkan berapa mengungkapkan 2687, 4038, dan 743 studi, masing-masing

banyak lebih besar kemungkinan memiliki air mata ACL (325 duplikat telah dihapus, meninggalkan 7143 studi). Satu

adalah untuk orang-orang dengan hasil tes positif daripada artikel yang disajikan dalam bentuk abstrak hanya tidak
dianggap. 76 Satu studi dikeluarkan karena teks lengkap
orang-orang dengan hasil tes negatif. DOR didefinisikan
dari artikel tidak dapat diperoleh. 57 Dengan tidak termasuk
sebagai: (positif sejati × negatif yang benar)
288.

sisa studi dianggap tidak memenuhi kriteria inklusi, 48 studi


-

tetap. Setelah evaluasi teks penuh 48 studi ini, 21 studi


(Salah
dikeluarkan. Lima dari 21 studi tidak menentukan akurasi
positif × negatif palsu). Ini adalah ringkasan tunggal kinerja
diagnostik per tes tapi mengomentari pemeriksaan klinis
tes diagnostik di mana sensitivitas, spesifisitas, LR +, dan komposit untuk cedera ligamen. 36,53,54,58,64 Artikel ini tidak
LR digabungkan. Kami memilih untuk menyajikan statistik termasuk data untuk pemeriksaan klinis atau bedah
ini dalam penelitian ini untuk meningkatkan perbandingan tertentu. Studi yang menggambarkan akurasi diagnostik
antara studi yang berbeda. 16 analisis subkelompok mengukur anterior kelemahan oleh instrumen, seperti KT-
dilakukan untuk menentukan apakah akurasi diagnostik 1000, juga dikecualikan. 6,7,14,40,70 Tiga dari 21 studi
berbeda dalam subgrup didefinisikan oleh karakteristik dikecualikan adalah artikel review. 45,62,67 Delapan studi
pasien. Kami mendefinisikan 4 subkelompok: pasien dengan tambahan tidak memenuhi kriteria inklusi. 21,25,37,41,43,46,65,66

ruptur akut dan kronis dari ACL dan pasien kepada siapa tes Satu studi, 55 yang tidak diindeks dalam 1 database tapi
diaplikasikan tanpa dan dengan anestesi. Mengenai diidentifikasi
klasifikasi pecah ACL akut dan kronis, kami mengikuti
keputusan yang diadopsi oleh penulis penelitian yang
termasuk dalam meta-analisis.
melalui komunikasi pribadi, telah ditambahkan ke studi berlatih di 11 studi. 5,10,12,13,26,27,30,34,50,52,69,72 Dalam 2 studi
disertakan. Dua penelitian yang sama.
artikel tergolong 55,63 hanya pasien
Secara keseluruhan, kami
50,52 laki-laki yang disertakan, sedangkan 9 studi 10,18,27,32,34,39,48,71,72 tidak

menganalisis 28 studi yang memenuhi kriteria inklusi. 5,8-10,12,13,18,20,26,27,30,32,34,35,menentukan jenis kelamin pasien disertakan. Jumlah pasien
termasuk per studi berkisar antara
38,39,42,44,48,50,52,55,60,61,63,69,71,72,74 Dua puluh tujuh dari studi 20 55 untuk
ini diidentifikasi 270 J
dalam MEDLINE, 10 di EMBASE, dan 1 di Orthop
CINAHL. 350. 27 Selain itu, rata-rata usia pasien berkisar antara 20
hingga 33 tahun. Usia pasien tidak ditentukan dalam 7
studi. 10,18,27,32,34,48,72
Sebuah penjelasan rinci tentang kualitas dan studi
metodologis karakteristik disajikan pada Tabel 2. Dua standar
emas yang berbeda, Artroskopi, dan arthrotomy, yang
digunakan dalam 7 penelitian, 5,12,27,32,44,48,61
Analisis
menggenang
yang masing-masing diterapkan untuk kelompok yang
berbeda dari pasien.
MRI digunakan dalam 2 studi. 8,39 Selain itu, 14 studi diterapkan Artroskopi
sensitivitasdikumpulkan, spesifisitas, LR +, LR, dan DOR untuk total populasi ditunjukkan
9,13,18,26,34,35,38,42,50,51,
55,60,63,69,71 dan 5 studi arthrotomy. 10,20,30,72,74 Hanya
pada
dalam 3 penelitian adadan Tabel 4A dan 7A untuk laci anterior dan tes Lachman, masing-masing. Data dikumpulkan untuk uji
Tabel 3A dan 6A
yang independen, perbandingan buta tes indeks
poros
dengan pergeseran
standar acuandisajikan dalam Tabel 5A dan 8A. Analisis kami menunjukkan bahwa tes Lachman adalah tes yang paling
diagnosis dan sebaliknya. 39,55,69 Selain itu, dalam 3
akurat untuk
studi standar acuanmenentukan pecah ACL. Selain itu, tes poros pergeseran menunjukkan sensitivitas yang sangat rendah dan
diterapkan terlepas dari hasil temuan dari tes indeks
spesifisitas yang
(menghindari bias sangat tinggi tanpa anestesi, 24% (95% Confidence Interval [CI], 21-27) dan 98% (95% CI, 96-99), masing-
verifikasi). 9,18,50,52 Hanya 3 studi menyebutkan bahwa tes
masing.
indeks diterapkan
secara independen dari semua informasi klinis lainnya.
12,55,60 Spektrum
kondisi kelompok eksperimen ( '' pasien sakit '') tidak
ditentukan atau tidak
jelas dalam 5 studi. 10,27,39,42,55 ACL pecah dengan lesi
bersamaan dengan
struktur jaringan lunak lain dari lutut yang dibahas dalam 19 studi,
5,8,9,18,20,26,30,32,34,35,38,44,

analisis dikumpulkan dari subkelompok klinis, pasien


dengan lesi akut dan kronis, ditunjukkan pada Tabel 3B dan
6B untuk tes anterior laci. Tanpa anestesi, tes laci anterior
menunjukkan sensitivitas yang lebih tinggi dan spesifisitas
di kronis dibandingkan dalam kondisi akut. Tabel 4B dan 7B
sedangkan 4 studi meneliti pasien
48,50,52,61,63,71,72,74
dan meja 5B dan 8B menunjukkan hasil untuk tes poros
dengan ruptur ACL
terisolasi spec- pergeseran Lachman dan masing-masing. Tes poros
(kecil pergeseran sangat spesifik baik dalam akut serta dalam
trum). 12,13,60,69 Tes Indeks digambarkan secara rinci
cukup untuk memungkinkan aplikasi dalam sendiri kondisi kronis.
Olahraga Phys Ther • Volume 36 • Nomor 5 • Mei
2006
20.188.74.123 on 08/29/19. For personal

TABLE 3A. tes anterior laci, tanpa anestesi, seluruh


kelompok.
Sensitivita Spesifisita
s s
use only.
288.
-
1
) )

Anderson et al, 1989 27 (14-43)


Boeree et al, 1991 56 (42-69) 92 (86-96) 6,7 (3,7-12,1) 0,5 (0,4-0,6) 14 (6-31)
Bomberg et al, 1990 41 (21-64) 100 (48-100) 5.0 (0,3-73,6) 0,6 (0,4-1,0) 8 (0-157)
Braunstein, 1982 91 (59-100) 100 (82-100) 33,3 (2,1-516,7) 0,1 (0,0-0,6) 259 (10-6945)
DeHaven, 1980 9 (2-23)
Donaldson et al, 1985 70 (60-79)
Hardaker et al, 1990 18 (11-27)
Hughston et al, 1976 58 (37-78) 50 (30-70) 1.2 (0,7-1,9) 0,8 (0,5-1,5) 1 (0-4)
Jonsson et al, 1982 95 (87-99)
Lee et al, 1988 78 (56-93) 100 (94-100) 87,9 (5,5-1399,9) 0,2 (0,1-0,5) 380 (20-7206)
Liu et al, 1995 61 (43-76)
Mitsou et al, 1988 40 (28-54)
Mitsou et al, 1988 95 (88-99)
Noyes et al, 1980 25 (15-37) 96 (79-100) 5,9 (0,8-42,3) 0,8 (0,7-0,9) 8 (1-60)
Rubinstein et al, 1994 † 76 (38-96) 87 (69-96) 5,6 (2,1-14,6) 0,3 (0,1-0,9) 20 (3-124)
Sandberg et al, 1986 39 (30-48) 97 (88-100) 11,2 (2,8-44,6) 0,6 (0,5-0,7) 18 (4-76)
Steinbruck et al, 1988 92 (81-98) 91 (87-94) 10.4 (6,9-15,7) 0,1 (0,0-0,2) 121 (40-368)
Tonino et al, 1986 27 (12-46) 100 (85-100) 12.6 (,8-207,6) 0,7 (0,6-0,9) 17 (1-313)
Torg et al, 1976 52 (44-61) 100 (95-100) 82.5 (5,2-1312,9) 0,5 (0,4-0,6) 171 (10-2821)
( (95%
L LRD Warren et al, 1978 71 (61-80) 77 (56-91) 3,095 (1,5-6,3) 0,4 (0,3-0,5) 8 (3-23)
9 CI)
R (95%
O
5 menggenang 55 (52-58) * 92 (90-94) * 7.3 (3,5-15,2) * 0,5 (0,4-0,6) * 21 (8-53) *
CI)
R
% + ukuran sampel hasil agregat 1809 1420 1420 1420 1420

C ( * P . 05.
(
I 9 Tes indeks diukur secara independen dari semua informasi klinis lainnya.
9 †
) 5 5
%%

C C
I I J Orthop Olahraga Phys Ther • Volume 36 • Nomor 5 • Mei 2006 271
88.74.123 on 08/29/19. For personal
use only.
288.
-
120.1
operman et al, 1990 † 1 (40-92) (30-77) (0,8-2,8) ,5 (0,2-1,4) (1-13)
Dahlstedt et al, 1989 100 (82-100)
Dahlstedt et al, 1989 100 (85-100)
DeHaven, 1980 80 (52-96)
TABLE 4A. tes
Lachman, tanpa Donaldson et al, 1985 99 (95-100)
anestesi, seluruh Harilainen 1987 98 (94-100) 98 (94-99) 40,0 (16,8-95,0) 0.0 (0,0-0,1) 1897 (446-8067)
kelompok. Hardaker et al, 1990 74 (65-82)
Jonsson et al, 1982 97 (89-100)
S
p Learmonth, 1991 68 (55-79) 94 (89-97) 10,7 (5,7-20,0) 0,3 (0,2-0,5) 31 (13,514-71)
e Lee et al, 1988 91 (72-99) 100 (94-100) 102.1 (6,4-1618,4) 0,1 (0,0-0,3) 972 (45-21.076)
s
Liu et al, 1995 95 (82-99)
i
f Mitsou et al, 1988 99 (94-100)
i Rubinstein et al, 1994 † 96 (60-100) 100 (89-100) 58,2 (3,7-917,4) 0,1 (0,0-0,7) 637 (19-21.843)
s
i
Sandberg et al, 1986 48 (39-57) 97 (88-100) 13,8 (3,5-54,5) 0,5 (0,5-0,6) 25 (6-109)
Sensi
t Schwarz et al, 1997 92 (80-98) 56 (25-85) 2.1 (1,1-4,1) 0,1 (0,0-0,4) 15 (3-72)
tivita
a Steinbruck et al, 1988 86 (74-94) 92 (88-95) 10,7 (7,0-16,6) 0,1 (0,1-0,3) 72 (29-180)
ss
( Tonino et al, 1986 90 (74-98) 100 (85-100) 40,8 (2,6-634,8) 0,1 (0,0-0,3) 354 (17-7210)
9 Torg et al, 1976 96 (92-99) 100 (95-100) 151,7 (9,6-2403,9) 0.0 (0,0-0,1) 3754 (205-68.805)
5 DO menggenang 85 (83-87) * 94 (92-95) * 10.2 (4,6-22,7) * 0,2 (0,1-0,3) * 70 (23-206) *
%
LR R ukuran sampel hasil
C LR(9+ (95 agregat 2276 1729 1729 1729 1729
(95%
I 5%%
(95%
CI)
) CI)CI)CI) * P . 05.
† Tes indeks diukur secara independen dari semua informasi klinis lainnya.
9
1
An
der (
so 7 TABLE 5A. pergeseran Pivot, tanpa anestesi, seluruh kelompok.
n 9
et - Sensitivitas Spesifisitas
al, 9 (95% CI) (95% CI) LR + (95% CI) LR (95% CI) DOR (95% CI)
19 8
89 ) Anderson et al, 1989 42 (27-58)
0 Boeree et al, 1990 31 (19-44) 97 (92-99) 8,8 (3,4-22,6) 0,7 (0,6-0,9) 12 (4-35)
,
Bomberg et al, 1990 9 (1-29) 100 (48-100) 1,3 (0,1-23,7) 1.0 (0,7-1,3) 1 (0-32)
6 4
3 ( Dahlstedt et al, 1989 9 (1-28)
0 Dahlstedt et al, 1989 72 (47-90)
Bo ( ,
DeHaven, 1980 9 (2-23)
ere 4 3
e 9 90 - Donaldson et al, 1985 35 (26-45)
et - (8 0 Hardaker et al, 1990 29 (20-39)
al, 7 4- 6,5, 16 Liu et al, 1995 71 (54-85)
19 5 95 6 (7-
(3,8-
Otter et al, 1994 ‡ 0 (0-71) 82 (57-96) 0,6 (0,0-10,1) 1.1 (0,7-1,7) 1 (0-14)
91 ) ) ) 33)
11,0)
0 Rubinstein et al, 1994 ‡ 93 (57-100) 89 (73-97) 8,5 (3,1-23,6) 0,1 (0,0-0,9) 114 (7-1967)
, Sandberg et al, 1986 6 (2-11) 100 (94-100) 7.1 (0,4-121,9) 0,9 (0,9-1,0) 7 (0-133)
8 2 Steinbruck et al, 1988 22 (11-35) 99 (97-100) 26,9 (6,1-117,5) 0,8 (0,7-0,9) 34 (7-159)
6 (
Tonino et al, 1986 17 (6 -35) 100 (85-100) 8.2 (0,5-140,3) 0,8 (0,7-1,0) 10 (1-185)
0
Bo ( , Torg et al, 1976 9 (5-15) 100 (95-100) 14.4 (,9-240,2) 0,9 (0,9-1,0) 16 (1-270)
mb 6 1 menggenang 24 (21-27) * 98 (96-99) * 8,5 (4,7-15,5) † 0,9 (0,8-1,0) * 12 (5-31) †
erg 5 60 - ukuran sampel hasil agregat 1431 1073 1073 1073 1073
et - (1 0
al, 9 5- 2.2, 10 * P . 05.
19 7 95 8 (1-
(0,7- † P . 05.
90 ) ) ) 83)
6,4)
‡ Tes indeks diukur secara independen dari semua informasi klinis lainnya.
Co 7 54 1,503

DISKUSI
Downloa

Orthop

Oleh karena itu, penting sosial ekonomi untuk benar


ded J

mendiagnosa patologi lutut ini. Dalam sintesis kualitatif

Tujuan dari kajian ini adalah untuk menentukan akurasi dan kuantitatif ini luas literatur, nilai-nilai yang berbeda

diagnostik uji klinis untuk mendeteksi pecah ACL. dari setiap tes untuk lesi akut dan kronis dengan atau

Peningkatan prevalensi cedera ACL ditambah dengan tanpa anestesi disajikan.


beban keuangan yang besar telah meningkatkan
kesadaran dalam kedokteran olahraga mengakibatkan
penyelidikan tentang cara untuk mengurangi risiko Kami termasuk lutut dengan lesi gabungan, seperti
cedera ACL. pecah ACL dengan MCL atau lateral ligamen kolateral

272 J Orthop Olahraga Phys Ther • Volume 36 • Nomor 5 • Mei 2006


TABLE 6A. tes anterior laci, dengan anestesi, seluruh kelompok.

Sensitivitas Spesifisitas

(95% CI) (95% CI) LR + (95% CI) LR (95% CI) DOR (95% CI)

Anderson et al, 1989 82 (67-92)


Bomberg et al, 1990 32 (14-55) 60 (15-95) 0,8 (0,2-2,7) 1.1 (0,5-2,5) 1 (0-5)
DeHaven, 1980 51 (34-69)
Donaldson et al, 1985 90 (83-95)
Hardaker et al, 1990 51 (40-61)
Hughston et al, 1976 100 (86-100) 23 (9-44) 1,3 (1,0-1,6) 0,1 (0,0-1,4) 16 (1-293)
Jonsson et al, 1982 98 (88-100)
Jonsson et al, 1982 98 (91-100)
Katz et al, 1986 41 (21-64) 95 (87-99) 8.6 (2,6-28,9) 0,6 (0,4-0,9) 14 (3-58)
Kim et al, 1995 80 (72-86)
Mitsou et al, 1988 93 (84-98)
on 08/29/19. For personal

Noyes et al, 1980 56 (42-69) 88 (68-97) 4,5 (1,5-13,2) 0,5 (0,4-0,7) 9 (2-33)
Sandberg et al, 1986 68 (60-76) 86 (75-94) 5.0 (2,6-9,5) 0,4 (0,3-0,5) 13 (6-31)
use only.

Tonino et al, 1986 57 (37-75) 100 (85-100) 26,0 (1,6-409,8) 0,4 (0,3-0,7) 58 (3-1051)
42861 (842-
Torg et al, 1976 100 (97-100) 100 (95-100) 157.4 (9,9-2.494,9) 0.0 (0,0-0,1) 2181398)
0,4 (0,2-0,8)
menggenang 77 (75-80) * 87 (82-91) * 5,9 (0,9-38,2) * * 19 (4-85) *
ukuran sampel hasil
agregat 1306 713 713 713 713

* P . 05.

W
LITERATUREREVIE
TABLE 7A. tes Lachman, dengan anestesi, seluruh kelompok.

Sensitivitas Spesifisitas

(95% CI) (95% CI) LR + (95% CI) LR (95% CI) DOR (95% CI)

Anderson et al, 1989 100 (92-100)


Bomberg et al, 1990 91 (71-99) 20 (1-72) 1.1 (0,7-1,8) 0,5 (0,1-4,1) 3 (0-35)
Dahlstedt et al, 1989 100 (85-100)
Dahlstedt et al, 1989 100 (82-100)
DeHaven, 1980 100 (78-100)
Donaldson et al, 1985 100 (96-100)
Hardaker et al, 1990 98 (93-100)
Jonsson et al, 1982 98 (88-100)
Jonsson et al, 1982 98 (91-100)
Katz et al, 1986 82 (60-95) 97 (89-100) 25.8 (6,5-102,2) 0,2 (0,1-0,5) 137 (23-811)
Kim et al, 1995 99 (95-100)
Mitsou et al, 1988 97 (89-100)
Sandberg et al, 1986 89 (82-94) 83 (71-91) 5.1 (2,9-9,1) 0,1 (0,1-0,2) 38 (16-91)
Tonino et al, 1986 93 (78-99) 100 (85-100) 42,3 (2,7-657,3) 0,1 (0,0-0,3) 513 (23-11.232)
42861 (842-
Torg et al, 1976 100 (97-100) 100 (95-100) 157.4 (10,0-2.494,9) 0.0 (0,0-0,1) 21811398)
0,1 (0,0-0,3)
menggenang 97 (96-98) * 93 (89-96) * 12,9 (1,5-108,5) * * 131 (15-1173) *
ukuran sampel hasil
agregat 1174 560 560 560 560

* P . 05.
(LCL) cedera. Selain itu, kita termasuk air mata parsial Namun, ini hanya terjadi di 2 studi 20,50,52 ( 3 pasien).
120.188.74.1
23 -288.

dalam analisis data mengikuti metodologi yang Kami tidak percaya bahwa jumlah yang sangat kecil ini
digunakan oleh penulis dari penelitian yang termasuk memiliki efek bias total meta-analisis, atau bahwa ini
dalam meta-analisis. Itu tidak mungkin untuk membuat akan menghasilkan hasil yang tidak akurat. Selain itu,
perbedaan antara total atau sebagian pecah dari ACL beberapa penelitian yang termasuk satunya subyek
dalam beberapa penelitian. Hanya di 2 studi 9,44 definisi dengan lutut ACL-kekurangan, atau tidak melaporkan
trueor hasil tes positif palsu. Itu tidak mungkin untuk
dari ACL air mata parsial dilaporkan. Lucie et al 44
menghitung spesifisitas (sehingga LR +, LR, dan DOR),
didefinisikan air mata ACL parsial sebagai ligamen yang
dalam studi ini dengan bias yang praseleksi.
tidak kehilangan kompetensi, sedangkan Bomberg dan
McGinty 9 didefinisikan sebagai air mata dari sebagian
dari ACL, meninggalkan sebagian dari serat ligamen
utuh. Berdasarkan definisi tersebut kita tidak
menganggap air mata ini sebagai ACL pecah dalam Lachman Uji
analisis data kami. Selain itu, kami termasuk pasien yang
memiliki cedera ACL bilateral dan dihitung pecah ini Hasil kami menunjukkan bahwa tes Lachman memiliki
sebagai 2 lutut independen. akurasi diagnostik yang baik untuk mendeteksi ACL
patologi, baik dalam akut serta dalam kondisi kronis.
P nelitian terbaru dari Scholten et al 62 telah
e menunjukkan pooled

J Orthop Olahraga Phys Ther • Volume 36 • Nomor 5 • Mei 2006 273


TABLE 8A. pergeseran Pivot, dengan anestesi, seluruh kelompok.

Sensitivitas Spesifisitas

(95% CI) (95% CI) LR + (95% CI) LR (95% CI) DOR (95% CI)

Anderson et al, 1989 93 (81-99)


Bomberg et al, 1990 59 (36-79) 60 (15-95) 1,5 (0,5-4,6) 0,7 (0,3-1,6) 2 (0-16)
Dahlstedt et al, 1989 70 (47-87)
Dahlstedt et al, 1989 83 (59-96)
DeHaven, 1980 63 (45-79)
Donaldson et al, 1985 98 (93-100)
Hardaker et al, 1990 73 (64-82)
Katz et al, 1986 82 (60-95) 98 (92-100) 51,5 (7,3-363,9) 0,2 (0,1-0,4) 279 (29-2656
Kim et al, 1995 90 (84-94)
Lucie et al, 1984 95 (83-99) 100 (69-100) 20,7 (1,4-310,2) 0,1 (0,0-0,2) 323 (14-7266
Sandberg et al, 1986 85 (77-91) 100 (94-100) 99,6 (6,3-1575,2) 0,2 (0,1-0,2) 633 (38-10.676)
Tonino et al, 1986 50 (31-69) 100 (85-100) 23,0 (1,5-364,9) 0,5 (0,4-0,7) 45 (3-809)
Torg et al, 1976 29 (21-37) 100 (95-100) 45,6 (2,8-731,0) 0,7 (0,6-0,8) 64 (4-1051)
menggenang 74 (71-77) * 99 (96-100) * 20,9 (2,8-156,2) * 0,3 (0,1-0,7) * 75 (11-518)
ukuran sampel hasil agregat 1077 610 610 610 610

* P . 05.

sensitivitas 86% (95% CI, 76-92) dan spesifisitas 91% 40% (95% CI, 29-52) dalam kondisi akut dan kronis, masing-
(95% CI, 79-96) untuk total populasi. Dengan CI yang masing. Data ini, di mana sensitivitas menggenang dalam
lebih kecil, hasil kami lebih tepat, menunjukkan kondisi kronis didasarkan, sangat heterogen. Menariknya,
sensitivitas dikumpulkan dari 85% (95% CI, 83-87) dan nilai antara 0% (95% CI, 0-71) 55 dan 93% (95% CI, 57-100) 60

spesifisitas 94% (95% CI, 92-95). Berdasarkan 12 dilaporkan. berbagai macam ini mungkin karena ukuran
penelitian, kita menghitung sebuah + LR keseluruhan sampel yang kecil, dan perbedaan waktu dari cedera, dan
10,2 (95% CI, dalam jenis pengaturan klinis. Ini lebih lanjut dapat
dijelaskan oleh fakta bahwa prevalensi ACL pecah dalam
4,6-22,7) dan LR 0,2 (95% CI, 0,1-0,3) ketika tes dilakukan studi Otter et al 55 hanya 15%, dan karena itu memiliki
tanpa anestesi.
kesempatan yang lebih kecil untuk mendiagnosis pecah ACL
karya terbaru dari Solomon et al 67 disajikan LR + dari 42,0
dibandingkan dalam studi Rubinstein et al, 60
(95%
CI, 2,7-651,0) dan LR 0,1 (95% CI, 0,0-0,4) untuk uji Lachman.
Namun,
data mereka memiliki CI yang lebih luas dan didasarkan pada
hanya 1
studi. 39 Posisi lutut selama tes ini (20 ° sampai 30 ° dari fleksi)
adalah posisi
yang kurang menyakitkan daripada posisi lutut selama uji
anterior laci; oleh yang memiliki prevalensi 22,5% pecah ACL. Kita tidak
karena itu, mengurangi aksi otot mungkin untuk melindungi lutut bisa
120.188.74.123 on 08/29/19. For personal

selama membandingkan hasil kami untuk total penduduk


pengujian. Selain itu, pembatasan sekunder tidak memberikan dengan hasil dari
kontribusi
use only.

Scholten et al, 62 karena mereka tidak menghitung


banyak untuk stabilitas di posisi tes ini. 49 Rosenberg dan Rasmussen 59 diukur
sensitivitas dikumpulkan

dan spesifisitas karena terbatasnya jumlah penelitian.


ketegangan ACL di 20 lutut normal dan mencatat bahwa Berdasarkan 8 studi,
ketegangan dasar
288.
-

di anteromedial dan bagian posterolateral dari ACL lebih


besar pada 15 ° kita menghitung sebuah LR + keseluruhan 8,5 (95%
dari fleksi dari pada 90 °. Sebuah tes Lachman diproduksi
ketegangan
maksimal dalam mayoritas ACL. Hal ini menjelaskan CI, 4,7-15,5) dan LR 0,9 (95% CI, 0,8-1,0) untuk pengujian
spesifisitas tes dilakukan tanpa
Lachman sebagai indikator integritas ACL. Meskipun anestesi. LR + dan LR dari tes ini tidak tersedia dalam
demikian, ada pekerjaan dari
beberapa keterbatasan untuk menguji. Sebagai contoh, Solomon et al 67 dan karena itu tidak dapat dibandingkan
pemeriksa yang dengan kita. Tes
memiliki tangan kecil mungkin menghadapi kesulitan pada poros pergeseran mereproduksi fenomena memberikan
pasien dengan jalan lutut. Sebuah
ketebalan paha besar. Selain itu, posisi lutut sangat penting tes positif menunjukkan kelemahan anterolateral dari lutut,
karena yang paling
mengurangi sudut fleksi 10 ° dapat mengakibatkan sering dilaporkan oleh pasien sebagai sensasi dikenali.
perjalanan menurun Alasan untuk
sensitivitas yang sangat rendah dalam kondisi kronis 55,69
dari tibia dan titik akhir palsu. 20 J Orthop
may Sports Phys Ther • Volume 36 • Number 5
be explained
• May 2006
by the fact that the patient with a chronic ACL-deficient
knee which tightens and therefore causes reduction of the
is displaced tibial
famil
plateau at approximately 30° of flexion. 65 Kim et al 35
iar
reported 15
with
this unpleasant phenomenon and will show
protectivePivot shift
muscle Uji
action.
Additionally, to perform this test, the MCL must
be intact to Kekhususan
build up enough
dari tes poros pergeseran sangat tinggi, yaitu 98% (95%
contact pressure in the
CI, 96-99). Kamilateral compartment.
menemukan, bagaimanapun, kepekaan yang sangat
Moreover, the pivot shift sign
miskin dari 32% (95% CI, 25-38) dan
is also intimately dependent upon the normal
function of the iliotibial tract,

274
J Orthop Sports Phys Ther 2006.36:267-288.
Downloaded from www.jospt.org by 120.188.74.123 on 08/29/19. For personal use only.
5 • May 2006
J Orthop Sports Phys Ther • Volume 36 • Number

TABLE 3B. Anterior drawer test, without anesthesia, acute and chronic subgroups.

LR+ DOR
(95% (95%CI
Sensitivity (95% CI) Specificity (95%CI) CI) LR– (95%CI) )

Ac
Acu ut
Acute Chronic Acute Chronic te Chronic Acute Chronic e Chronic

Anderson et
al, 20 (6-42) 60 (27-88)
1989
5.0
Bomberg et 100 (48- (0.3- 0.6 (0.4- 8 (0-
al, 41 (21-64) 100) 73.6) 1.0) 157)
1990

DeHaven, 1980 9 (2-23)

Donaldson et al, 1985


70 (60-
79)
1.2
Hughston et 50 (30- (0.7- 0.8 (0.5- 1 (0-
al, 58 (37-78) 70) 1.9) 1.5) 4)
1976

Jonsson et al, 95 (87-99)


1982
Liu et al, 1995 61 (43-
76) Mitsou et

al, 1988
40 (28-54) 95 (88-99)

Rubinstein et 20 (3-
al, 76 (38-96) 87 (69-96) 5.6 (2.1-14.6) 0.3 (0.1-0.9) 124)
1994 ‡

Steinbru¨ck 10.4 (6.9-


et al, 92 (81-98) 91 (87-94) 15.7) 0.1 (0.0-0.2) 121 (40-368)
1988
49 (43- 58 (39- 1.4 (0.5- 8.9 (5.3-15.2) 0.7 (0.5- 0.1 (0.0-0.5) 2 (1-7) 57 (10-
Pooled 55)* 92 (88-95)* 76)* 91 (87-94) † 4.4) † † 1.0) † † † 330) †

Sample size 298 531 77 375 77 375 77 375 77 375


aggregate

results

* P . 05.
† P . 05.
‡ Index test measured independently of all other clinical information.
5
27
LITERATUREREVIEW
J Orthop Sports Phys Ther 2006.36:267-288.
Downloaded from www.jospt.org by 120.188.74.123 on 08/29/19. For personal use only.
6
27

TABLE 4B. Lachman test, without anesthesia, acute and chronic subgroups.

LR+ DOR
Specificity (95%C (95%CI
Sensitivity (95% CI) (95%CI) I) LR– (95%CI) )

Ac
ut
Acute Chronic Acute Chronic Acute Chronic Acute Chronic e Chronic

Anderson et 91 (71- 100 (69-


al, 99) 100)
1989
2.2
Bomberg et 86 (65- (0.7- 0.2 (0.1-
al, 97) 60 (15-95) 6.4) 0.8) 10 (1-83)
1990
Cooperman 71 (40- 54 (30- 0.5 (0.2-
et al, 92) 77) 1.5 (0.8-2.8) 1.4) 3 (1-13)
1990 †
Dahlstedt et 100 (85-100) 100 (82-
al, 100)
1989
80 (52-
DeHaven, 96)
1980
Donaldson 99 (95-
et al, 100)
1985
40.0 1897
5 • May 2006
J Orthop Sports Phys Ther • Volume 36 • Number

98 (94- (16.8- 0.0 (0.0- (446-


Harilainen, 100) 98 (94-99) 95.0) 0.1) 8067)
1987
Jonsson et 97 (89-
al, 100)
1982
73 (56- 100 (81-
Learmonth, 86) 100)
1991
95 (82-
Liu et al, 99)
1995
99 (94-
Mitsou et al, 100)
1988
Rubinstein 96 (60- 100 (89- 58.2 (3.7- 0.1 (0.0-
et al, 100) 100) 917.4) 0.7) 637 (19-21843)
1994 †
Steinbru¨ck 86 (73- 92 (88- 10.7 (7.0- 0.1 (0.1-
et al, 94) 95) 16.6) 0.3) 72 (29-180)
1988
94 (91- 95 (91- 97 (93- 90 (87- 9.4 (0.4-210.0)* 7.1 (1.2- 0.1 (0.0-1.1)* 0.2 (0.1- 143 (1-25936)*
Pooled 96)* 97)* 99)* 94)* 40.2)* 0.7)* 38 (2-572)*

Sample size 613 598 377 407 377 407 377 407 377 407
aggregate
results
* P . 05.
† Index test measured independently of all other clinical information.
J Orthop Sports Phys Ther 2006.36:267-288.
Downloaded from www.jospt.org by 120.188.74.123 on 08/29/19. For personal use only.
5 • May 2006
J Orthop Sports Phys Ther • Volume 36 • Number

TABLE 5B. Pivot shift, without anesthesia, acute and chronic subgroups.

Sensitivity (95%
CI) Specificity (95%CI) LR+ (95%CI) LR– (95%CI) DOR (95%CI)

Chroni
Acute Chronic Acute Chronic Acute Chronic Acute Chronic Acute c

Bomberg et 9 (1- 100 (48- 1.3 (0.1- 1.0 (0.7- 1 (0-


al, 29) 100) 23.7) 1.3) 32)
19
90
Dahlstedt et 9 (1- 72 (47-
al, 28) 90)
1989

DeHaven, 1980 9 (4-17)


Donaldson et al, 1985
35 (26-45)

Liu et al, 1995 71 (54-85) Otter et

al, 1994 ‡
82 (57- 0.6 (0.0- 1.1 (0.7-
0 (0-71) 96) 10.1) 1.7) 1 (0-14)

Rubinstein 93 (57- 89 (73- 8.5 (3.1- 0.1 (0.0- 114 (7-


et al, 100) 97) 23.6) 0.9) 1967)
1994 ‡

Steinbru¨ck 22 (11- 99 (97- 26.9 (6.1- 0.8 (0.7-


et al, 35) 100) 117.5) 0.9) 34 (7-159)
1988
32 (25- 40 (29- 100 (48- 97 (95- 1.3 (0.1- 7.7 (1.6- 1.0 (0.7- 0.8 (0.4- 1 (0-
Pooled 38)* 52)* 100) 99)* 23.7) 36.4) †,‡ 1.3) 1.4)* 32) 16 (1-218)*

Sample size 224 413 27 395 27 395 27 395 27 395


aggregate

results

* P . 05.
† P . 05.
‡ Index test measured independently of all other clinical information.
7
27

LITERATUREREVIEW
8
27
J Orthop Sports Phys Ther 2006.36:267-288.
Downloaded from www.jospt.org by 120.188.74.123 on 08/29/19. For personal use only.

TABLE 6B. Anterior drawer test, with anesthesia, acute and chronic, subgroups.

LR+ DOR
Specificity (95% (95%CI
Sensitivity (95% CI) (95%CI) CI) LR– (95%CI) )

Acu
Acute Chronic Acute Chronic te Chronic Acute Chronic Acute Chronic

Anderson et
5 • May 2006
J Orthop Sports Phys Ther • Volume 36 • Number

al, 21 (7-43) 61 (27-88)


1989
0.8
Bomberg et 32 (14- 60 (15- (0.2- 1.1 (0.5-
al, 55) 95) 2.7) 2.5) 1 (0-5)
1990
DeHaven, 1980 51 (34-
69)

Donaldson et al, 1985

90 (83-95)
1.3
Hughston et 100 (86- (1.0- 0.1 (0.0- 16 (1-
al, 100) 23 (9-44) 1.6) 1.4) 293)
1976
98 (88- 98 (91-
Jonsson et al, 100) 100)
1982
7.0
97 (89- 100 (94- (1.1- 68.6 (4.2- 0.8 (0.6- 0.5 (0.3-
Katz et al, 22 (3-60) 54 (25-81) 100) 100) 43.7) 1131.8) 1.1) 0.8) 9 (1-72) 147 (7-2869)
1986
Kim et al, 99 (95-
1995 100)
93 (84-
Mitsou et al, 98)
1988
78 (73- 75 (64- 100 (94- 1.5 (0.7- 68.6 (4.2- 0.8 (0.4- 0.5 (0.3- 4 (1-27)
Pooled 82)* 94 (91-97)* 83)* 100) 3.3) † 1131.8) 1.7) † 0.8) † 147 (7-2869)

Sample size 412 295 149 72 149 72 149 72 149 72


aggregate
results

* P . 05.
† P . 05.
5 • May 2006
J Orthop Sports Phys Ther • Volume 36 • Number
J Orthop Sports Phys Ther 2006.36:267-288.
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9
27

TABLE 7B. Lachman test, with anesthesia, acute and chronic subgroups.

LR+
Sensitivity (95% Specificity (95%
CI) (95%CI) CI) LR– (95%CI) DOR (95%CI)

Acute Chronic Acute Chronic Acute Chronic Acute Chronic Acute Chronic

Anderson et 93 (73- 100 (69-


al, 99) 100)
1989
Bomberg et 91 (71- 1.1 (0.7- 0.5 (0.1-
al, 99) 20 (1-72) 1.8) 4.1) 3 (0-35)
1990
Dahlstedt et 100 (85- 100 (82-
al, 100) 100)
1989
100 (78-
DeHaven, 100)
1980
Donaldson et 100 (96-
al, 100)
1985
98 (88- 98 (91-
Jonsson et al, 100) 100)
1982
78 (40- 85 (55- 97 (89- 100 (94- 24.5 (6.0-100.1) 0.2 (0.1- 0.2 (0.1- 107 (13- 584 (26-
Katz et al, 97) 98) 100) 100) 105.1 (6.6-1680.9) 0.8) 0.6) 881) 12977)
1986
Kim et al, 99 (95-
1995 100)
97 (89-
Mitsou et al, 100)
1988
97 (95- 98 (95-99) 91 (82- 100 (94- 5.0 (0.1-188.3)* 105.1 0.3 (0.1- 0.2 (0.1- 18 (0- 584 (26-
Pooled 99)* † 97)* 100) (6.6-1680.9) 0.8) † 0.6) 727)* 12977)

Sample size 365 313 99 72 99 72 99 72 99 72


aggregate
re-
sults

* P . 05.
† P . 05.

LITERATUREREVIEW
0
28
J Orthop Sports Phys Ther 2006.36:267-288.
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TABLE 8B. Pivot shift, with anesthesia, acute and chronic subgroups.
5 • May 2006
J Orthop Sports Phys Ther • Volume 36 • Number

Sensitivity (95% CI) Specificity (95%CI) LR+ (95%CI) LR– (95%CI) DOR (95%CI)

Chro Chro
Acute Chronic Acute Chronic Acute nic Acute Chronic Acute nic

Bomberg et 60 (15- 1.5 (0.5- 0.7 (0.3- 2 (0-


al, 59 (36-79) 95) 4.6) 1.6) 16)
1990
Dahlstedt et 83 (59-
al, 70 (47-99) 96)
1989
DeHaven 1980 63 (45-
79)

Donaldson et al, 1985


98 (93-
100)
Katz et al, 1986 89 (52- 85 (55- 100 (94- 98 (92- 108.8 (6.8-1741.9) 0.2 (0.0- 0.2 (0.0- 720 (27-19120)
100) 98) 100) 100) 53.3 (7.5-377.7) 0.7) 0.6) 341 (28-4091)
Kim et al, 90 (84-
1995 94)
100 (69- 20.7 (1.4- 0.1 (0.0- 323 (14-
Lucie et al, 95 (83-99) 100) 310.2) 0.2) 7266)
1984
85 (80- 89 (83- 97 (91-100)* 98 (92- 12.6 (0.5-305.3)* 0.2 (0.0- 0.2 (0.0- 67 (1-3604)* 341
Pooled 90)* 93) † 100) 53.3 (7.5-377.7) 1.0)* 0.6) (28-4091)
7 7
Sample size 308 241 149 72 149 2 149 72 149 2
aggregate
results

* P . 05.
† P . 05.

false-negative results of the pivot shift test in chronic Posttest Probabilities in Acute and Chronic Conditions
condition, caused by reattachment of a torn ACL to the
proximal portion of the PCL in 7 of the 15 patients, as
confirmed by arthroscopic examination. It is commonly
Sensitivity and specificity only describe how
believed that the accuracy of a complex test maneuver
abnormality—in this case a rupture of the ACL—predicts
such as the pivot shift test may increase with
a test result. 17 However, for clinical practice it is
experience. 67
essential to know how a test result predicts abnormality.
Likelihood ratios provide this information. According to a
prospective investigation from Noyes et al, 50

Anterior Drawer Test st


ro
ng
The anterior drawer test is widely used in the diagnosis of
ly
ACL injuries. Our results show that the test has unacceptable
aff
low sensitivity and specificity for use in the clinical setting,
ec
especially in acute condition (49% [95% CI, 43-55] and 58%
te
[95% CI, 39-76], respectively). Torg et al 72 noted 3 possible
d
causes for a false-negative anterior drawer test in acute
120.188.74.123 on 08/29/19. For personal

by
condition, especially in isolated ACL tears. First, the
co
hemarthrosis and reactive synovitis may preclude knee
nc
flexion to 90°, hindering the proper performance of the test.
use only.

o
Second, protective muscle action of the hamstrings secondary
mi
to joint pain provides a vector force opposite to the anterior
ta
translation of the tibia. Third, the posterior horn of the medial
nt
meniscus becomes buttressed against the posteriormost
inj
margin of the medial femoral condyle and may preclude
288.
-

ur
anterior translation of the tibia. 72 In addition, this test is
y
and
44.0% of patients with acute knee injuries (defined as
becom
individuals who suffered a traumatic knee injury
es
associated with a rapid onset of swelling [ie, a
increa
hemarthrosis] with or without the sensation of a pop)
singly CI, 88-95] and 91% [95% CI, 87-94], respectively). For have a completely torn ACL. In other words, the pretest
positiv the total population, we calculated a pooled sensitivity probability of having an ACL rupture in these patients
e if and specificity of 55% (95% CI, 52-58) and 92% (95% CI, is 44.0%. We calculated that in acute cases the LR+ of
secon 90-94), respectively. With a somewhat wider CI, Scholten the Lachman test is 9.4 (95% CI,
dary et al 62 presented almost the same values of the pooled
restrai sensitivity and specificity. They calculated a sensitivity
nts of 62% (95% CI, 42-78) and a specificity of 88% (95% CI, 0.4-210.0). From this value the posttest probability can
are 83-92). The anterior drawer test was found to have the be calculated, which is 88.1%. So a positive Lachman test
injure best diagnostic value for the LR+, LR–, and DOR in

W
LITERATUREREVIE
increases the probability of a ruptured ACL from 44.0%
d. In chronic lesions as compared to the other tests that were to 88.1% in this population. A LR– of 0.1 (95% CI, 0.0-
chroni analyzed in this study. Based on 12 studies, we 1.1), in case of a negative Lachman test, changes the
c calculated an overall LR+ of 7.3 (95% CI, 3.5-15.2) and a pretest probability from
condit LR– of
ion,
when 44.0% of having an ACL rupture to a posttest probability
there of 7.3% in patients with acute knee injuries, as described
is less by Noyes et al. 50 A negative Lachman test therefore
effusi 0.5 (95% CI, 0.4-0.6) when tested without anesthesia. decreases the probability of having a ruptured ACL from

on, Recent work from Solomon et al 67 indicated a LR+ of 44.0% to 7.3%. This is shown in the nomogram in Figure
3.8 (95% CI, 0.7-22.0) and a LR– of 0.3 (95% CI, 2.
pain,
muscu 0.1-1.5). However, these data, with a wide CI, were

lar based on 3 studies only. 10,30,39 The high diagnostic


values in chronic condition could be attributed to the According to an other prospective investigation from
protec
fact that patients who initially had isolated ACL injury Steinbru¨ck et al, 69 22.3% of patients with chronic knee
tion,
may develop progressive knee laxity over time due to injuries (not defined in this study) have a completely torn
and
the failure of the secondary restraints. ACL. So, the pretest probability of having an ACL rupture in
proba
these patients is 22.3%. We calculated that in chronic cases
bly
the LR+ of the Lachman test is 7.1 (95% CI, 1.2-40.2). From
progre
this value the posttest probability of having a ruptured ACL
ssive
can be calculated, which is 67.1%. So
knee
a positive Lachman test in chronic conditions increases
laxity
the probability of a ruptured ACL from 22.3% to 67.1%.
due to
A LR– of 0.2 (95% CI, 0.1-0.7) results in a posttest
failure
probability of 5.4% in case of a negative Lachman test.
of the A negative Lachman test, therefore, decreases the
secon probability of having a ruptured ACL from 22.3% to
dary 5.4%.
restrai
nts,
the
sensiti
vity
and The LR+ of the pivot shift test in acute condition is
specifi 1.3 (95% CI, 0.1-23.7). With a pretest probability of an ACL
rupture of
city of
the 44.0%, 50 this results in a posttest probability of a torn
ACL of 50.5%, in case of a positive pivot shift test. A LR–
anteri
of 1.0 (95% CI,
or
drawe
0.7-1.3) in case of a negative pivot shift test does not
r test
change the pretest probability of 44.0% of having a
are
ruptured ACL, the posttest probability is also 44.0%.
much
So, only a positive pivot shift test gives a relatively
better
small increase of 6.5% of the probability for having a
(92% ruptured ACL.
[95%

The LR+ of the pivot shift test in chronic


condition is 7.7 (95% CI, 1.6-36.4), with a pretest
probability of
J Orthop Sports Phys Ther • Volume 36 • Number 5 • May 2006 281

anterior drawer test decreases the probability of having a


ruptured ACL by 8.5%.
The anterior drawer test shows a LR+ of 8.9 (95%
CI, 5.3-15.2) in chronic conditions. Assuming that the
pretest probability of having an ACL rupture is
22.3%, 69 this results in a posttest probability of a torn ACL
of 71.9%. A positive anterior drawer test in chronic
conditions therefore increases the probability of having an
ACL rupture from 22.3% to 71.9%. A LR– of 0.1 (95% CI, 0.0-
0.5) results in a posttest probability of 2.8% of having an
ACL rupture in case of a negative anterior drawer test.
Therefore, a negative anterior drawer test decreases the
probability of having an ACL rupture by 19.5%.

The Role of Anesthesia in the Diagnostic Accuracy of


Testing

The accuracy of the tests may have been affected by


factors such as swelling, pain, and protective muscle
action. Anesthesia eliminates protective muscle guarding,
which enhances the accuracy in confirmatory tests such as
the pivot shift. So, anesthesia adds to the diagnostic
precision. The overall sensitivity of the pivot shift test for
example is 74% (95% CI, 71-77) under anesthesia, but in
the alert patient this percentage decreases to 24% (95%
CI, 21-27). Such change was not present when analyzing
the overall specificity of this test.
FIGURE 2. Nomogram: posttest probability using the Lachman
test to detect an anterior cruciate ligament (ACL) rupture. A:
With a LR+ of 9.4 (95% CI, 0.4-210.0), the pretest probability
of 44.0% of having an ACL rupture changes after a positive
Lachman test to a posttest probability of 88.1% of having a There were a few studies 18,30,63,72,73 in which the anterior
ruptured ACL. B: A LR– of drawer or the pivot shift tests could not be performed or
0.1 (95% CI, 0.0-1.1) in case of a negative Lachman test were inconclusive without anesthesia, because of pain or
only.

decreases the pretest probability of 44.0% of having an ACL


use

muscular protection. In these cases, the authors reported


rupture to a posttest probability of 7.3% of having a
the number of knees or a percentage of the total
ruptured ACL.
participating knees in which the test was equivocal. In our
data analysis we regarded these cases as false or as true
negative.
120.188.74.123 on 08/29/19. For

having a torn ACL of 22.3%. 69 This results in a posttest 44.0%, 50 this results in a posttest probability of a torn ACL
probability of an ACL rupture of 68.8% in case of a positive of 52.4%. A positive anterior drawer test, therefore,
personal

test. So a positive pivot shift test in chronic conditions increases the probability of having an ACL rupture by 8.4%.
increases the probability of a ruptured ACL from 22.3% to A LR– of 0.7 (95% CI, 0.5-1.0) in case of a negative anterior
68.8%. A LR– of 0.8 (95% CI, 0.4-1.4) results in a posttest drawer test changes the pretest probability from 44.0% of
probability of a ruptured ACL of 18.7% in case of a negative having a ruptured ACL to a posttest probability of 35.5%.
288.

pivot shift test. A negative pivot shift test therefore results


-

So, a negative
in a small decrease of the probability of having an ACL
rupture from 22.3% to 18.7%.

The anterior drawer test shows a LR+ of 1.4


(95%

CI, 0.5-4.4) in acute conditions. Again assuming that the


pretest probability of having an ACL rupture is
ACL ruptures are generalizable only to settings that have a Second, this meta-analysis is based on heterogeneous
Limitations similar spectrum of patients. Furthermore, technical details data. This heterogeneity might be caused by differences in
of the Study of the tests may also vary from one setting to another and study design, setting, the spectrum of the diseased and
limit generalizability. 31 Other limitations must be nondiseased groups, the threshold of the index test, and
Valid addressed in this study. First, we made the methodological the reference standard. 15 The number of patients examined
estimates of choice to include partial ACL tears in the data analysis. in the studies reviewed was an important determinant of
the
the precision of the estimate of the accuracy of the
diagnostic
examination. This is reflected in the confidence interval,
accuracy of
which is smaller
the 3 tests
for detecting

282 J Orthop Sports Phys Ther • Volume 36 • Number 5 • May 2006


o s
n t
l a
in case of a higher number of subjects. The individual showed a pooled sensitivity of 49% (95% CI, 42-56) for the y t
studies used different studies with 3 i
methods of grading the clinical tests. These differences highest quality, 9,18,39,50,52,69 compared to 56% (95% CI, 53-59) s s
make direct for the rest of t t
comparison of various studies difficult. Therefore, it is the studies with lower quality. However, this difference is not u i
recommended to use clinically d c
accepted scores like the IKDC form, 2,28 allowing better relevant, as both estimates are too low to be acceptable for i s
comparison among the use of this e .
patient populations. Moreover, the sensitivity of the test in clinical setting. The specificity of the anterior drawer s
physical examination test is 93% 9,

may be overstated because of potential biases in most (95% CI, 89-95) for the studies with the highest 1

studies. These methodological quality 9,39,50,52,60,69 8,

physical examination maneuvers have been validated most and 91% (95% CI, 88-94) for the studies with lower 5

in patients who methodological quality. 0,

We calculated a sensitivity of 86% (95% CI, 78-91) and 85% 5

are referred for surgery. (95% CI, 2

83-87) for the studies with the highest 9,12,18,39,60,69 and the h
studies with lower a
methodological quality, respectively, for the Lachman test. d
The specificity of n
o
the Lachman test is 92% (95%
v
Third, we included studies with a mixture of
e
methodological
r
characteristics. However, we identified and reported the
i
differences, as
f
recommended by Ju¨ni et al. 33 This is shown in Table 2.
i
The scoring system
c
we used did not give us the opportunity to calculate an
a
overall
t
methodological score of the included studies. However, the CI, 88-94) for the studies with the highest methodological
i
use of quality 9,12,39,60,69 and
o
composite quality scales is not recommended, nor is the
n
use of summary 95% (95% CI, 93-96) when excluding these studies. The pivot b
scores. To identify studies of high quality is problematic shift test i
because the type of shows a sensitivity of 20% (95% CI, 14-29) for the studies with a
the highest s
scale used to assess quality can dramatically influence the
(
interpretation of methodological quality and 25% (95% CI, 21-28) for
9,18,55,60,69 A
the meta-analysis. 33 Moreover, the incorporation of quality the rest of the 4
scores as studies with lower methodological qualities. The difference )
between the .
weights lacks statistical and empirical justification. 19 In
T
addition, we specificities is just 1%, showing 97% (95% CI, 95-99) for the h
performed a sensitivity analysis to calculate the pooled studies with i
120.188.74.123 on 08/29/19. For personal

estimates of the s
p
studies of better and poorer methodological quality based the highest methodological quality 9,55,60,69 and 98% (95%
r
on criteria A3 o
(index test and reference standard measured blind of each
use only.

b
other), A4 l
(reference standard applied regardless of the results of e
the findings from m
the index tests), and C3 (index test measured
independently of all other CI, 96-100) when excluding these studies. These results g
288.

indicate that the o


-

clinical information) of the scoring system we used. Three studies 39,55,69 measured
e
the index test and reference standard blind of each other methodological scores of the scoring system we used did have s
(A3). In addition, very little b
influence on the magnitude of the pooled diagnostic accuracy e
yo and thus not given the chance to be
nd tests were followed up with anesthesia. This may lead to bias
th because the
e proven to have false-negative results. 56 Furthermore, only 3 studies 12,55,60 mentioned

bia that the index test was applied independently of all other results of the test performed first could influence the testers’
s clinical information grading of
of (C3). We considered these 3 criteria as the most important subsequent tests. Considering these aspects, there is
ev in view of undoubtedly a
alu potential bias and therefore may have had the greatest growing need for studies based on sound research with a high
ati influence on the level of
ng magnitude of the pooled diagnostic accuracies. We evidence. 3 In these studies the reference standard should,
th investigated the likely consequently, be
e impact of these important factors on the key findings. performed independent of the index test and vice versa. In
tes Overall, there was a addition, the
t tendency that the pooled estimates of the studies with
onl better reference standard should be applied blindly to all patients. 3

y methodological quality 9,12,18,39,50,52,55,60,69 were a little bit lower when


in
compared with the pooled estimates of the studies with poorer
a
hig methodological quality. However, these were just minor changes certainly
h- not clinically relevant. More specifically, when we look at the performance
pr of the tests without anesthesia, the greatest difference was for the anterior
ev
drawer test, which
ale
nc CONCLUSION
e
po Based on this meta-analysis, our study clearly indicates
pul that the
ati
Lachman test has a high diagnostic accuracy in terms of
on,
sensitivity and
be L

W
LITERATUREREVIE
ca a specificity. Moreover, the pivot shift test has a very high
us s specificity both in
e t acute as well as in chronic conditions and therefore should
pa l also be
tie y
performed. The anterior drawer test has a high diagnostic
nts ,
accuracy for the
wit
h 2 chronic ACL-deficient knee. It should be recognized that
po the results of the
te o anterior drawer test in acute condition and the sensitivity
nti r of the pivot shift
all test clearly increase in the anesthetized patient.
y 3
fal
se- c
ne l
ga i
tiv n
e i
res c
ult a
s l
ar t
e e
ha s
rdl t
y s
ev
er w
ev e
alu r
ate e
d
by c
th o
e n
cri d
ter u
ion c
sta t
nd e
ar d
d

J Orthop Sports Phys Ther • Volume 36 • Number 5 • May 2006 283


ACKNOWLEDGMENTS 16. Deeks JJ. tinjauan sistematis evaluasi dari diagnos- tes tic
dan penyaringan.
Dalam: Egger M, Smith GD, Altman DA, eds. Sistematis Ulasan di
This meta-analysis is the continuation of the Kesehatan. London, UK: BMJ Books; 2001:

graduation research thesis of the first author, which


17. Deeks JJ, Altman DG. Diagnostic tests 4: likelihood ratios.
was supervised by Anneke J. Beetsma, PT, MSc. We BMJ. 2004;329:168-169.
give special thanks to Jean-Michel Brismé´e, PT, ScD,
from Texas Tech University Health Sciences Center, for 18. DeHaven KE. Diagnosis of acute knee injuries with
hemarthrosis. Am J Sports Med. 1980;8:9-14.
critically reviewing the manuscript. We also thank
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286 J Orthop Sports Phys Ther • Volume 36 • Number 5 • May 2006


Appendix
CRITERIA FOR STUDY VALIDITY

A1. Was a definition of a positive test result of the reference standard(s) stated?
Please indicate the type of reference standard(s).

O Arthrotomy yes/no
O Arthroscopy yes/no
O MRI yes/no
O Other (please indicate) yes/no
O Tipe standar acuan tidak ditunjukkan

A2. Apakah setiap standar referensi diterapkan untuk semua mata pelajaran?

Sebuah. iya nih


b. Tidak ada (jelaskan secara singkat)

c. Tidak berlaku (hanya satu standar referensi telah diterapkan)

A3. Apakah tes indeks (s) dan standar referensi diukur secara independen (buta) satu sama lain?

SebuahUji. Index (s) diukur secara independen dari standar acuan (s) dan standar acuan secara independen dari uji indeks (s)
b. Uji Index (s) diukur secara independen dari standar acuan (s) tetapi tidak sebaliknya
c. standar acuan (s) diukur secara independen dari uji indeks (s) tetapi tidak sebaliknya
d. uji indeks (s) dan standar acuan (s) tidak diukur secara independen satu sama lain

LITERATUREREVIE
e.jelas

A4. Apakah pilihan pasien yang dinilai dengan standar acuan (s)
independen dari hasil tes index (s)? (Penghindaran bias
verifikasi)

a. The reference standard(s) was (were) measured in consecutive patients (inception cohort) and thus independently of the
index test’s results
120.188.74.123 on 08/29/19. For personal

b. The reference standard(s) was (were) measured in a random sample of patients who were positive or negative by
the index test and the results were adjusted for different sample fractions in the statistical analysis
c. The reference standard(s) was (were) measured in patients who were selected for assessment by the reference
use only.

standard for various rea- sons (including the condition of interest)


d. The reference standard(s) was (were) measured in patients who were selected for assessment by the reference standard
for the condi- tion of interest

e. The selection of patients for the assessment by the reference standard(s) was not independent of the index test’s
results or no adjust- ment was made for different sample fractions in the statistical analysis
288.
-

f. Unclear

A5. Study design.

a. Prospective (evidence of research planning)


b. Retrospective (no evidence of research planning)
c. Unclear

A6. Was a description included regarding missing data?

a.Yes
b. No
c. Not applicable (no missing values)

CRITERIA RELEVANT TO THE APPLICABILITY OF THE RESULTS

B. The clinical problem

B1. Source of population involved in the study (setting):

a. Primary care on non-referred patients


b. Secondary care (first level of referral)
c. Tertiary care (teaching hospitals)
d. Mixed population
e. Not specified/ unclear

B2. Spectrum of the condition of the ‘‘diseased’’ (according to the reference standard):

a. Combined lesions
b. Only isolated lesion of interest
c. Not specified/ unclear
J Orthop Sports Phys Ther • Volume 36 • Number 5 • May 2006 287

B3. Spectrum of the condition of the ‘‘non-diseased’’ (according to the reference standard):

a. Subjects with various other lesions of the knee


b. Subjects with an isolated lesion of one other knee structure
c. Healthy subjects only
d. Not specified/ unclear

B4. Were the inclusion and exclusion criteria defined?

a.Yes
b. No

B5. Was there a description of previous tests/other clinical information to which the index test was being
evaluated?

a.Yes
b. No

C. The index test(s)

The following questions pertain to all index test(s)/ to index test:

C1. Was the index test described in sufficient detail to enable its application in one’s own practice?

a. Yes, described in text/literature reference


b. No

C2. Was a definition of a positive test result of the index test stated?

a. Yes (please indicate)


b. No

C3. Was the index test measured independently of all other clinical information?

a.Yes
b. No
c. Not specified/unclear

C4. Were subjects excluded because the index test was unfeasible or the index test’s result
was considered indeterminate?

a. Yes (please indicate how many cases)


b. No
c. Not specified/ unclear

C5.Was the reproducibility of the index test described?

a.Yes
b. No
120.188.74.123 on 08/29/19. For personal
use only.
288.
-

288 J Orthop Sports Phys Ther • Volume 36 • Number 5 • May 2006


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