Table 1 Characteristics of included studies
From: Lever sign test for anterior cruciate ligament injuries: a diagnostic meta-analysis
No. | Study | Year | Country | Study design | Blindness | Participant | No. of participants | Age (years) |
|---|---|---|---|---|---|---|---|---|
1 | Lelli | 2014 | Italy | Cohort | Yes | Patients with a definitive MRI diagnosis of unilateral ACL rupture (partial or complete) | 281 males 119 females | 26.43 ± 14.9 |
2 | Deveci | 2015 | Turkey | Cohort | Yes | Patients diagnosed with ACL tear which was definitively determined during an arthroscopic surgical procedure | 96 males 21 females | 25.8 ± 5.9 (17–45) |
3 | Chong | 2017 | USA | Cohort | NM | Patients who presented to the lead orthopedic surgeon with a unilateral knee injury that resulted in symptomatic instability at two selected facilities | 21 males 12 females | Male:30.9 ± 14.3 (11–62) female: 30.6 ± 17.0 (15–60) |
4 | Mulligan | 2017 | USA | Cohort | Yes | Patients with a complaint of knee pain rated as less than 7/10 on a verbal numerical rating scale, possessing at least 20–120° range of motion | 38 males 22 females | 42 ± 13.4 (18–65) |
5 | Thapa | 2015 | Nepal | Cohort | NM | Patients with knee symptoms of giving way/locking/pain following sports or non sports injury | 50 males 30 females | Mean 32.12 (21–42) |
6 | Massey | 2017 | USA | Cohort | Yes | Presenting after a noncontact or contact knee injury with subjective swelling, or an objective effusion, and uninjured normal contralateral knee for comparison (no previous injury or surgery) | 61 males 30 females | 28 ± 7 |
7 | Jarbo | 2017 | USA | Cohort | Yes | Patients with a chief concern of acute knee pain who came for an evaluation within 4 weeks of their injury or the onset of symptoms | 58 males 44 females | Mean 23 (15–66) |
8 | Lichtenberg | 2018 | Netherland | Cohort | NM | Patients ≥ 16 years old, suffered from knee trauma, and had indications for knee arthroscopic surgery | 57 males 37 females | 34 ± 15 |
9 | Polat | 2019 | Turkey | Cohort | NM | Patients who had contact or noncontact knee injuries up to 2 weeks prior to the examination and who did not have any previous history of knee injury | 69 males 9 females | 26.2 ± 6.4 (17–44) |
10 | McQuivey | 2019 | USA | Cohort | NM | Patients with probable acute ACL tears without other previous or simultaneous knee pathology in patients ages 12–55 years | 25 males 20 females | Mean 33 (12–54) |
11 | Marcel | 2020 | Brazil | Cohort | Yes | Patients with a history of previous knee sprains | 49 males 23 femals | 33.2 ± 8.6 |
12 | Kevin | 2021 | Belgium | Cohort | NM | Patients above 18 years, presenting at the ED for acute knee pain, following an acute trauma within 8 days, with an initial radiograph showing no signs of fracture (except Segond fracture or tibial spine fracture) | 52 (with a 2 M/1F sex distribution) | Mean 33 (19–56) |
13 | Camille | 2021 | France | Cohort | NM | Patients aged 18 and over who were living in France, recent unilateral knee injury (less than 7 days) with clinical suspicion of ACL injury (cracking, instability, apprehension, effusion) and a normal X-ray | 68 males 190 femals | 42.2 ± 13.4 |
No. | Study | Trauma period | Gold standard | Sample size | Sensitivity (%) | Specificity (%) | TP | FP | FN | TN |
|---|---|---|---|---|---|---|---|---|---|---|
1 | Lelli | Acute: ≤ 20 days chronic: > 20 days | MRI | Lever Sign test: 100 | 100.00 | 100.00 | 400 | 0 | 0 | 0 |
Lachman test: 100 | 62.00 | 100.00 | 247 | 0 | 153 | 0 | ||||
Anterior Drawer test: 100 | 72.00 | 100.00 | 287 | 0 | 113 | 0 | ||||
Pivot Shift test: 100 | 47.00 | 100.00 | 188 | 0 | 212 | 0 | ||||
2 | Deveci | 8.7 weeks (4–25 weeks) | MRI & arthroscopy | Lever Sign test (pre-anaesthesia): 117 | 94.00 | UTC | UTC | UTC | UTC | UTC |
Lachman test (pre-anaesthesia): 117 | 80.00 | UTC | UTC | UTC | UTC | UTC | ||||
Anterior Drawer test (pre-anaesthesia): 117 | 60.00 | UTC | UTC | UTC | UTC | UTC | ||||
Pivot Shift test (pre-anaesthesia): 117 | 62.00 | UTC | UTC | UTC | UTC | UTC | ||||
Lever Sign test (under anaesthesia): 117 | 98.00 | UTC | UTC | UTC | UTC | UTC | ||||
Lachman test (under anaesthesia): 117 | 88.00 | UTC | UTC | UTC | UTC | UTC | ||||
Anterior Drawer test (under anaesthesia): 117 | 88.00 | UTC | UTC | UTC | UTC | UTC | ||||
Pivot Shift test (under anaesthesia): 117 | 88.00 | UTC | UTC | UTC | UTC | UTC | ||||
3 | Chong | NM | Arthroscopy | Lever Sign test (pre-anaesthesia, EOS): 33 | 88.00 | UTC | 29 | 0 | 4 | 0 |
Lachman test (pre-anaesthesia, EOS): 33 | 94.00 | UTC | 31 | 0 | 2 | 0 | ||||
Pivot Shift test (pre-anaesthesia, EOS): 33 | 27.00 | UTC | 11 | 0 | 24 | 0 | ||||
Lever Sign test (under anaesthesia, EOS): 33 | 97.00 | UTC | 32 | 0 | 1 | 0 | ||||
Lachman test (under anaesthesia, EOS): 33 | 100.00 | UTC | 33 | 0 | 0 | 0 | ||||
Pivot Shift test (under anaesthesia, EOS): 33 | 97.00 | UTC | 32 | 0 | 1 | 0 | ||||
Lever Sign test (pre-anaesthesia, EOPA): 33 | 82.00 | UTC | 27 | 0 | 6 | 0 | ||||
Lachman test (pre-anaesthesia, EOPA): 33 | 67.00 | UTC | 22 | 0 | 11 | 0 | ||||
Pivot Shift test (pre-anaesthesia, EOPA): 33 | 9.00 | UTC | 3 | 0 | 30 | 0 | ||||
Lever Sign test (under anaesthesia, EOPA): 33 | 100.00 | UTC | 33 | 0 | 0 | 0 | ||||
Lachman test (under anaesthesia, EOPA): 33 | 94.00 | UTC | 31 | 0 | 2 | 0 | ||||
Pivot Shift test (under anaesthesia, EOPA): 33 | 76.00 | UTC | 25 | 0 | 8 | 0 | ||||
4 | Mulligan | NM | Injury history interview or review of previously conducted radiographic or MRI | Lever Sign test (direct visual assessment of ACL): 19 | 33.00 | 50.00 | 5 | 2 | 10 | 2 |
Lever Sign test (application of clinical cluster of findings): 41 | 44.00 | 75.00 | 4 | 8 | 5 | 24 | ||||
5 | Thapa | NM | Arthroscopy | Lever Sign test: 80 | 85.71 | 91.11 | 30 | 5 | 5 | 40 |
Lachman test: 80 | 91.42 | 95.55 | 32 | 2 | 3 | 43 | ||||
Pivot shift test: 80 | 51.42 | 100.00 | 18 | 0 | 17 | 45 | ||||
Anterior drawer test: 80 | 80.00 | 93.33 | 28 | 3 | 7 | 42 | ||||
6 | Massey | NM | MRI | Lever Sign test: 91 | 83.00 | 80.00 | 59 | 4 | 12 | 16 |
Lachman test: 91 | 89.00 | 85.00 | 63 | 3 | 8 | 17 | ||||
Pivot shift test: 83 | 66.00 | 94.00 | 44 | 1 | 23 | 15 | ||||
Anterior drawer test: 91 | 82.00 | 80.00 | 58 | 4 | 13 | 16 | ||||
7 | Jarbo | ≤ 4 weeks | MRI & arthroscopy | Lever Sign test: 102 | 63.00 | 90.00 | 32 | 5 | 19 | 46 |
Lachman test: 102 | 90.00 | 96.00 | 46 | 2 | 5 | 49 | ||||
Pivot shift test: 102 | 59.00 | 98.00 | 29 | 1 | 20 | 52 | ||||
Anterior drawer test: 102 | 88.00 | 94.00 | 45 | 3 | 6 | 48 | ||||
8 | Lichtenberg | NM | Arthroscopy | Lever Sign test: 87 | 39.00 | 100.00 | 16 | 0 | 25 | 46 |
Lachman test: 93 | 87.00 | 91.00 | 40 | 4 | 6 | 43 | ||||
Pivot shift test: 81 | 50.00 | 98.00 | 20 | 1 | 20 | 40 | ||||
Anterior drawer test: 91 | 71.00 | 94.00 | 39 | 2 | 16 | 34 | ||||
9 | Polat | ≤ 2 weeks | MRI | Lever Sign test (acute): 78 | 91.90 | 93.80 | 57 | 1 | 5 | 15 |
Lachman test (acute): 78 | 80.60 | 62.50 | 50 | 6 | 12 | 10 | ||||
Pivot shift test (acute): 78 | 51.60 | 93.80 | 32 | 1 | 30 | 15 | ||||
Anterior drawer test (acute): 78 | 77.40 | 68.80 | 48 | 5 | 14 | 11 | ||||
Lever Sign test (preanesthesia): 78 | 91.90 | 93.80 | 57 | 1 | 5 | 15 | ||||
Lachman test (preanesthesia): 78 | 83.90 | 68.80 | 52 | 5 | 13 | 12 | ||||
Pivot shift test (preanesthesia): 78 | 56.50 | 93.80 | 35 | 1 | 27 | 15 | ||||
Anterior drawer test (preanesthesia): 78 | 79.00 | 75.00 | 49 | 4 | 13 | 12 | ||||
10 | McQuivey | NM | MRI | Lever Sign test: 21 | 100.00 | 93.80 | 5 | 1 | 0 | 15 |
Lachman test /Anterior drawer test: 24 | 40.00 | 100.00 | 6 | 0 | 9 | 9 | ||||
11 | Marcel | > 1 months | MRI | Lachman test (without anesthesia): 72 | 94.80 | 100.00 | 55 | 0 | 3 | 14 |
Anterior Drawer test (without anesthesia): 72 | 82.00 | 84.85 | 32 | 5 | 7 | 28 | ||||
Lever Sign test (without anesthesia): 72 | 64.10 | 100.00 | 41 | 0 | 8 | 23 | ||||
12 | Kevin | ≤ 8 days | MRI | Lever Sign test: 52 | 92.50 | 25.00 | 37 | 9 | 3 | 3 |
Lachman test: 52 | 54.00 | 54.50 | 22 | 5 | 19 | 6 | ||||
Anterior Drawer test: 52 | 56.00 | 82.00 | 23 | 2 | 18 | 9 | ||||
13 | Camille | ≤ 7 days | MRI | Lever Sign test: 258 | 61.20 | 27.80 | 134 | 26 | 85 | 10 |
Lachman test: 258 | 99.10 | 5.60 | 217 | 34 | 2 | 2 |