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- Arch Bone Jt Surg
- v.1(2); 2013 Dec
- PMC4151408
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Arch Bone Jt Surg. 2013 Dec; 1(2): 94–97.
Published online 2013 Dec 15.
PMCID: PMC4151408
PMID: 25207297
Hadi Makhmalbaf, MD, Ali Moradi, MD, Saeid Ganji, MD, and Farzad Omidi-Kashani, MD
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Abstract
Background:
The knee joint is prone to injury because of its complexity and weight-bearing function. Anterior cruciateligament (ACL) ruptures happen in young and physically active population and can result in instability, meniscal tears, andarticular cartilage damage. The aim of this study is to evaluate the accuracy of Lachman and anterior drawer tests in ACLinjury in compare with arthroscopy.
Methods:
In a descriptive, analytical study from 2009 to 2013, 653 patients who were suspected to have ACL rapture wereentered the study. Statistical analysis was performed by the usage of SPSS 16. Multiple comparison procedures were performedfor comparing data between clinical examination and arthroscopic findings and their relation with age and sex.
Results:
Mean age of patients was 28.3±7.58 years (range from 16 to 68 years). From 428 patients, 41.2% (175 patients)were between 26 and 35, 38.8% (165 ones) between 15 and 25 and 20% (85 patients) out of 36 years. 414 patients were male(97.2%) and 12 were female (2.8%). Sensitivity of anterior drawer test was 94.4% and sensitivity of Lachman test was 93.5%.
Conclusion:
The diagnosis of the ACL injury and the decision to reconstruct ACL could be reliably made with regards tothe anterior drawer and Lachman tests result. The tests did not have privilege to each other. The test accuracy increasedconsiderably under anesthesia especially in women.
Keywords: Accuracy, Anterior drawer test, Lachman test
Introduction
The knee joint is prone to injury because of its anatomicorientation and weight-bearing function. Anteriorcruciate ligament (ACL) rupture occures inyoung and physically active population and could resultin instability followed by, meniscusal tears, and articularcartilage damage if not well treated (1). It is estimatedthat 80,000 to 100,000 ACL reconstructions is performedin the United States annually. studies have shown a 1.4 to9.5 times increased risk of ACL tear in women (2, 3). MRIis the most common imaging study for ACL injury in USA.MRI could show not only ACL tear but also shows any othersoft tissue or bone injuries (4). Immediately after injury,if the condition allows (pain and swelling), the knee mustbe evaluated to diagnose any ACL tear or other injuries(5). A thorough physical examination is the first step inevaluating a patient with knee pain after injury. Differentstudies has confirmed that a proper and complete kneeexamination can be sensitive for ACL injury in more than80 percentages of cases. Physical examination should bestarted from patient`s gait observation plus taking careful history (6). Ligament laxity measurement is clinicallyvaluable to diagnosis injury and also to compare laxity beforeand after surgical procedure. However, the level of instabilityand laxity does not correlate with patients’ signsand symptoms (7).
The Lachman (anterior displacement of tibial manuallyat 20° of flexion) is an accurate test for detecting ACL tear(mean sensitivity 84%) (2, 8, 9). Anterior drawer test andthe pivot shift tests have a sensitivity of about 62 percent.Increasing pressure to reduce health care expenses, leadsto investigate new methods to increase the precision ofclinical tests which could be achieved through variousreviews evaluating the diagnostic accuracy of these tests(10).
The aim of this study is to evaluate the accuracy of Lachmanand anterior drawer tests in the knee with ACL injuryin compare with arthroscopy findings.
Materials and Methods
Between 2009 and 2013, in a descriptive, analyticalstudy, 653 patients who were suspected of having ACL rapture diagnosed by general orthopedic surgeons, sportmedicine specialist or general practisoners admitted inour referral hospital for further evaluation. After historytaking and physical examination and imaging studiesevaluation, by the senior author of our study, 428 patientsbecame candidates for knee arthroscopy. The ethical approvalto conduct the study was obtained from MashhadUniversity of Medical Sciences. Exclusion criteria wereprevious knee surgery, deformity or contracture. All thesubjects had non-acute ACL injuries with more than 3weeks passed from the incident with the normal otherside for comparative evaluation.
History
Data was collected by a junior orthopedic surgeon whichincluded: demographic information (age and gender),ACL rupture etiology and history and patient chief complaintat the time of admission.
Physical examinations
All physical examinations were performed blindly by oneorthopedic resident trained in knee examination. Physicalexaminations included: anterior drawer and Lachmantests. These two tests were performed twice for each patient,first in clinic and second time under general anesthesiabefore reconstruction of ACL on the operating table.The examiner checked the affected side with normal onein all cases. Knee arthroscopic surgeries were performedby our senior who specialized in knee surgery not awareof physical examination results.
Anterior drawer test
With the patient in supine position, the hip and kneewere flexed to 45 and 90 degrees respectively. While thefoot was stabilized on the examination table and the hamstringswere relax, frequent manual gentle antro-posteriorforces were applied to the proximal tibia, and tibia antero-posteriordisplacement in flexed knee was measured. Thedegree of displacement was compared with normal side.Displacement of more than 6mm comparing the oppositeside with a soft end point was proposed as torn ACL.
Lachman test
The Lachman test is carried out in relax supine position,the examiner bends the knee to about 15 degreesand slightly external rotation. Then, by stabilizing thefemur with one hand and putting the other hand behindthe proximal tibia at the level of joint line, and then thetibia is pulled forward. In normal response there shouldbe a steady restraint to anterior movement. Anterior displacement of proximal tibia being felt by examiner thumbin a soft or mushy end point was associated with positiveLachman test. Grade of laxity was defined by the amountof anterior tibial movement.
Statistical analyzes
Statistical analysis was performed by the usage of SPSS16. Multiple comparison procedure was performed forcomparing data between clinical examination and arthroscopicfindings and their relation with age and sex. Sensitivitywas considered as number of true positives to numberof true positives and false negatives and specificity asnumber of false positives to number of false positives andtrue negatives (5).
Results
Mean age of patients was 28.3±7.58 years (range from16 to 68 years). From 428 patients, 41.2% (175 patients)were between 26 and 35, 38.8% (165 patients) between15 and 25 and 20% (85 patients) over 36 years. 414 patientswere male (97.2%) and 12 were female (2.8%).
Etiology of ACL injury was shown in Table Table1.1. The mostcommon cause of ACL injury was sport activities (75.7%)such as football, volleyball, wrestling and etc.
Table 1.
Causes of ACL injury
| Causes | Frequency |
|---|---|
| Sport | 316 (75.7%) |
| Unknown Trauma | 49 (11.4%) |
| Fall | 27 (6.3%) |
| Car accidents | 15 (3.5%) |
| Work accidents | 8 (1.9%) |
| Other | 2 (0.3%) |
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Among 316 ACL ruptures due to sports activities, 233(74%) happened during football, 50 (16%) during wrestlingand other contact-sport, 19 (6%) during volleyball, 8(3%) at basketball, 5 (2%) at handball and 1(0.3) duringskiing.
Patients` chief compliant were; giving away 308 (72.4%),locking 82 (189.3%) and pain 35 (8.2%).
In Table Table2,2, the initial (with clinical examination) and final(after arthroscopy) diagnoses was compared. In 75.6%,ACL injuries the clinical examination were compatiblewith arthroscopic diagnosis. ACL rupture in associationwith of lateral meniscus rupture was led to the most misdiagnosisof our cases.
Table 2.
First (clinical examination in clinic) and final (arthroscopic) diagnoses
| Site of injury | Physical examination | Arthroscopic diagnoses | Sensitivity | Specificity |
|---|---|---|---|---|
| ACL rupture and medial meniscus injury | 244 (57.3%) | 208 (48.8%) | 95% | 82% |
| ACL rupture | 148 (34.7%) | 112 (26.3%) | 98% | 90% |
| ACL rupture and lateral meniscus injury | 15 (3.5%) | 53 (12.4%) | 52% | 99% |
| ACL rupture and both meniscus injury | 4 (0.9%) | 42 (9.9%) | 56% | 100% |
| ACL and PCL rupture and meniscus injury | 4 (0.9%) | 2 (0.5%) | 100% | 99% |
| Medial meniscus injury | 6 (1.4%) | 3 (0.7%) | 75% | 98% |
| ACL rupture and meniscus injury and OA | 5 (1.2%) | 5 (1.2%) | 83% | 99% |
| Medial and lateral meniscus injury | 0 | 1 (0.2%) | 50% | 100% |
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Sensitivity of anterior drawer test was 94.4% and its sensitivity with general anesthesia was 96.4%. This sensitivitywas not related to age (P>0.05). Sensitivity of anteriordrawer test in clinic was significantly different in men andwomen (95%vs. 72.7%, P=0.018) but not under generalanesthesia (96.6% vas 91.7%, P=0.19).
Sensitivity of Lachman test was 93.5% and its sensitivityunder general anesthesia was 96.9%. This sensitivitywas not related to age (P>0.05). Sensitivity of Lachmantest in clinic was significantly different in men and women(66.7%vs. 94.6%, P=0.005) but not under general anesthesia(97.3% vas 91.7%, P=0.317).
Discussion
After ACL rupture, most patients have detectable signsand symptoms of excess knee laxity and the joint becomesunstable. Anterior tibial translation in normal knees hasvery little different in right and left knees and in 95% ofnormal population; this difference is less than 2 mm. It iscrucial to use the contralateral normal knee as control tocompare the difference in laxity between normal and injuredknees (9).
In our study the sensitivity of anterior drawer test inclinic was 94.4% and its sensitivity with general anesthesiawas 96.4%. This sensitivity was not related to age(P>0.05). Sensitivity of anterior drawer test in clinic wassignificantly different in men and women (95%vs. 72.7%,P=0.018). Lachman test sensitivity was respectively 93.5%and 96.9% in and after general anesthesia which was notassociated with age (P>0.05). Sensitivity of Lachmantest in clinic did not differ in male and female (66.7%vs.94.6%, P=0.005). Anterior drawer and Lachman tests didnot have privilege to each other. Physical examination inwomen were more sensitive under general anesthesiathan in clinic. It did not apply in men.
Several studies confirmed that the sensitivity of diagnostictests such as anterior drawer and Lachman wouldincrease in chronic ACL injuries (9, 7, 11). On the otherhand, it has been demonstrated that knee diagnostic testaccuracy rose under anesthesia which is suggestive of theimportance of patient factor in the sensitivity of thesetests (12).
Oberlander evaluated the diagnostic accuracy of kneeclinical examination and his study resulted in 63% sensitivityof the tests (13). In Benjaminse`s meta- analysis, the accuracy for Lachman test showed a pooled sensitivity of85% (14). Jain revealed the sensitivity of the Lachman testunder anesthesia to be 92.9 % (15).
Liu showed that the sensitivity of Lachman and anteriordrawer test was 95 and 61%, respectively (16). Lachmantest sensitivity rose to 100% under anesthesia. Lee et alshowed that the sensitivity of MR imaging was 94% . comparedwith 78% for the anterior drawer test and 89% forthe Lachman test. Katez et al concluded that in all ACLinjuries, irrespective of age, the Lachman test was 81.8%sensitive and 96.8% specific; the anterior drawer sign was40.9% sensitive and 95.2% specific; and the pivot shiftwas 81.8% sensitive and 98.4% specific.
Regarding to high sensitivity of Lachman test a negativetest result, provides a strong clinical suspicion for rullingout the ACL injury (17,18). Jonsson et al concludedin examining an acutely injured knee in a patient withoutanesthesia, the Lachman test was superior to the anteriordrawer sign, but, in chronic injuries, both the tests hadhigh diagnostic accuracy (19).
Lachman and anterior drawer tests are subjective andoperator dependent tests; then, the results of this studyshould be considered with more caution. The experienceand precision of examiner will influence the end result ofthe test. For as much as general practitioners who are atthe first line of dealing with patients are less experiencedin carrying out these tests, the tests inevitably would beless accurate in primary care and outpatient clinics (7,12).
The anterior drawer and Lachman tests are valuablemeans to assess ACL injuries. The tests did not have privilegeto each other. The accuracy of these test increasedconsiderably under anesthesia especially in women.
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Articles from Archives of Bone and Joint Surgery are provided here courtesy of Mashhad University of Medical Sciences
