Evaluating the diagnostic pathway for acute ACL injuries in trauma centres: a systematic review

Abstract

Objective This review sought to evaluate the literature on the initial assessment and diagnostic pathway for patients with a suspected Anterior Cruciate Ligament (ACL) tear. Methods MEDLINE, EMBASE, and CINAHL were systematically searched for eligible studies, PRISMA guidelines were followed. Studies were included if they used at least one assessment method to assess for ACL injury and participants were assessed at an acute trauma centre within 6-weeks of injury. Article quality was evaluated using the QUADAS-2 checklist. Results A total of 353 studies were assessed for eligibility, 347 were excluded for the following reasons: injuries were not assessed in an acute trauma setting, injuries were not acute, participants had previous ACL injuries or chronic joint deformities affecting the knee, participants were under 18, or participants included animals or cadavers. A total of six studies were included in the review. Common assessment methods included: laxity tests, joint effusion, inability to continue activity, and a history of a ‘pop’ and ‘giving way’ at the time of injury. Diagnostic accuracy varied greatly between the assessment method and the assessing clinician. Gold standard diagnostics were MRI and arthroscopy. A weighted meta-mean calculated the time to reach diagnosis to be 68.60 days [CI 23.94, 113.24]. The mean number of appointments to reach diagnosis varied from 2–5. Delay to surgery or surgical consultation ranged from 61 to 328 days. Conclusion Clinicians in the Emergency Department are not proficient in performing the assessment methods that are used for diagnosis in acute ACL injury. Reliance on specialist assessments or radiological methods inevitably increases the time to reach a diagnosis, which has repercussions on management options. There is an ever-growing demand to improve diagnostic accuracy and efficiency; further exploration into quantitative measures of instability would aid the assessment of peripheral joint assessment.

Identifying Anterior Cruciate Ligament Injuries Through Automated Video Analysis of In-Game Motion Patterns

“…Patients who rupture their ACL do not always have the injury correctly diagnosed and attempt to return to play prematurely. 1 Failure to identify ACL tears may lead to severe consequences in terms of further injuries, delayed treatment, poor recovery, and slow return to sports. 3 , 12 , 30 , 32 , 35 Because performing a clinical examination in the acute stage is frequently hampered by the substantial knee pain and swelling that follows the injury, a magnetic resonance imaging (MRI) evaluation may bring valuable information about the status of the ACL.…”

“…Previous studies have reported that the correct diagnosis rate at initial medical evaluation is less than 30%, 1,3 particularly in cases where patients are initially seen by physicians in hospital emergency departments, by primary care physicians, or by physiotherapists. 1,3 There are specific and reliable movements associated with ACL injuries, such as high knee abduction moment and dynamic valgus. 9,14,15,22 Laboratory investigations, mathematical modeling, and video analyses have been used to evaluate those specific movements, 5,13,19 but only video analysis, which uses recordings from a sports event, allows for the evaluation of kinematics in a real game setting.…”

“…Despite its typical injury pattern, achieving an accurate diagnosis of ACL rupture remains a challenge. Previous studies have reported that the correct diagnosis rate at initial medical evaluation is less than 30%, 1,3 particularly in cases where patients are initially seen by physicians in hospital emergency departments, by primary care physicians, or by physiotherapists. 1,3 There are specific and reliable movements associated with ACL injuries, such as high knee abduction moment and dynamic valgus.…”

Association of Emergency Department Evaluation With Public Insurance Use and Treatment Delays for ACL Injury

“…Unfortunately, it has been previously shown that ED providers do not diagnose these injuries accurately. 1 In addition, ED visits have been found to add a mean of US$4857 in cost to ACL injury care despite reduced diagnostic accuracy. 16…”

“…Unfortunately, it has been previously shown that ED providers do not diagnose these injuries accurately. 1 In addition, ED visits have been found to add a mean of US$4857 in cost to ACL injury care despite reduced diagnostic accuracy. 16 A previous study has found that patients with public insurance have a greater propensity to utilize the ED after a musculoskeletal injury.…”