Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : April | Volume : 16 | Issue : 4 | Page : RC15 - RC19 Full Version

Comparison of the Lever Sign Test, Anterior Drawer Test and Lachman Test in Cases of Anterior Cruciate Ligament Tear: A Prospective Cohort Study


Published: April 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/51898.16277
Gagandeep Singh, Manish Singh, Pallav Gupta

1. Senior Resident, Department of Orthopaedics, Government Medical College, Jammu, India. 2. Consultant, Department of Orthopaedics, Government Medical College, Jammu, India. 3. Senior Resident, Department of Orthopaedics, Government Medical College, Jammu, India.

Correspondence Address :
Dr. Manish Singh,
Consultant, Department of Orthopedics, Government Medical College, Jammu, India.
E-mail: drmanish_singh@yahoo.co.in

Abstract

Introduction: The Anterior Cruciate Ligament (ACL) is a very commonly injured ligament of knee. Several physical examination tests are performed for evaluating ACL stability. The Lachman, pivot-shift, and anterior drawer tests are commonly performed for evaluating the knee laxity.

Aim: To compare Lever sign test with anterior drawer test and Lachman test in case of ACL tear, and to assess preanaesthesia and postanaesthesia variability in tests results.

Materials and Methods: This prospective cohort study was conducted at Government Medical College, Kathua, Jammu, India, from October 2018 till September 2019. Total 50 patients were included (age group 18-60 years) with symptomatic ACL tear requiring diagnostic arthroscopy or repair. Three test included Lever sign test, anterior drawer test and Lachman test were performed preanaesthesia and postanaesthesia and findings were recorded. Sensitivity and specificity was calculated preanaesthesia and postanaesthesia. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0. The p-value ≤0.05 was considered statistically significant.

Results: Total 50 patients were evaluated and analysed including 60% males (n=30) and 40% females (n=20). The mean age of the patients was 34.5±2.6 years. Sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Values (NPV) and diagnostic accuracy of anterior drawer test preanaesthesia were 83%, 87%, 97%, 50%, and 84%, respectively, and postanaesthesia were 88%, 87%, 97%, 58%, and 88%; for Lachman test preanaesthesia were 88%, 87%, 97%, 58%, and 88%, respectively, and postanaesthesia were 90%, 87%, 97%, 63%, and 90%; and for Lever sign test preanaesthesia were 85%, 88%, 100%, 57%, and 88%, and postanaesthesia were 88%, 100%, 100%, 61%, and 90%, respectively. There was no significant difference in the diagnostic accuracy of the three tests while comparing for preanaesthesia and postanaesthesia or for individual tests (p>0.05).

Conclusion: The lever test showed high specificity, but comparable diagnostic accuracy in the detection of ACL tears in comparison to anterior drawer test and Lachman test. All the tests hold equal importance for diagnosing ACL tears before and after anaesthesia.

Keywords

Diagnostic tests, Knee ligament injury, Management, Sensitivity

The knee is one of the most frequently injured joint. The cruciate ligaments act as stabilisers of the joint and axis around which rotatory motion, both normal as well as abnormal movements take place (1). The ACL is a very commonly injured ligament. The leading causes include sports injuries and vehicular trauma. Nearly 200,000 ACL injury annually were reported in US and 75000-100,000 ACL reconstruction are performed each year (2),(3).

In the case of an ACL injury, knee laxity is usually evaluated by physical examination using the Lachman (4), pivot-shift (5),(6), and anterior drawer tests (7). Galway RD et al., described the pivot shift test in 1972 and Torg JS et al., described the Lachman test in 1976 (8),(4). In 2014 a new test ‘Lever sign test’ was introduced by Lelli A with 1.00 sensitivity (9). Previous studies have reported different sensitivity and specificity for these tests for partial and complete tear, chronic and acute injuries, interobserver variability, and preanaesthesia and postanaesthesia variability. It has been reported consistently in many previous studies that the Lachman test had the highest sensitivity (85% to 96%) and the pivot shift test consistently had the highest specificity (97% to 99%) (10),(11),(12).

An ideal test would have both a high sensitivity and specificity and be easily reproducible. It can be used in both chronic and acute cases, can diagnose both partial and complete tear, same result with or without anaesthesia and with no interobserver variability. A reproducible, split test, which can be easily performed by the practitioners in the emergency room, office, or training room (12).

There is a scarcity of studies conducted in India that compared these tests in resource limited settings especially in terms of pre- and postanaesthesia changes, thus bringing on the novelty of the study. These tests hold the importance as they can be done without any additional cost and can provide a prediction about the ACL tears. Thus, this study was conducted with an aim to compare Lever sign test with anterior drawer test and Lachman test in case of ACL tear and to assess preanaesthesia and postanaesthesia variability in tests results.

Material and Methods

The prospective cohort study was conducted at Government Medical College, Kathua, Jammu, India, from October 2018 till September 2019. Ethical clearance was taken from Government Medical College, Jammu, Institutional Ethical Committee (IEC/GMC/2019/838). An informed consent was taken from patients before enrolling in the study.

Inclusion criteria: The study population included patients in age group 18-60 years with isolated complete ACL tear, with meniscal injury, chondral injuries, and medial/lateral collateral ligament sprains.

Exclusion criteria: Any patients with associated Posterior Cruciate Ligament (PCL) injury, ACL reinjury, periarticular fracture, and ipsilateral lower limb fractures were excluded from the study.

Sample size calculation: The sample size was calculated based on the study of Gürpinar T et al., who observed that sensitivity of Lachman, anterior drawer and lever was 80.6%, 77.4% and 91.9%, respectively and specificity of Lachman, anterior drawer and lever was 62.5%, 68.8% and 93.8%, respectively (13). Taking these values as reference, the minimum required sample size with desired precision of 20%, 80% power of study and 5% level of significance is 41 patients. To reduce margin of error, total sample size taken was 50.

Total 54 patients belonging to age group 18-60 years with symptomatic ACL tear requiring diagnostic arthroscopy or repair admitted in hospital were evaluated, among which four were lost to follow-up and thus the final data pertains to 50 patients.

Formula used is for testing sensitivity and specificity of single diagnostic test (13):

1. For sensitivity

Where, Se is sensitivity, Zα is value of Z at two sided alpha error of 5% and Zβ is value of Z at power of 80%

2. For specificity

Where Sp is specificity, Zα is value of Z at two sided alpha error of 5% and Zβ is value of Z at power of 80%.

The details pertaining to the demography, injury characteristics, and clinical features, such as pain, swelling, lack of range of motion were noted for all the patients. All the enrolled patients in the study underwent lever test, anterior drawer test and Lachman test twice: once before anaesthesia for the surgery and once again after the anaesthesia. It is because anaesthesia relieves the patient apprehension and pain, thereby allowing for the tests to be solely on the basis of the injury and can lead to better accuracy of the tests in diagnosing the injury.

Tests Employed

Anterior drawer test: The anterior drawer test was done when patient was told to lie in the supine position. Flexion of the hip was done to 45° and that of knee to 90°. For stabilising the leg, the examiner sat on the feet of patient. The forward force was given to the tibia after the hamstring muscles were relaxed. The positive anterior drawer test was suggested in the presence of forward movement of >6–8 mm compared to the normal knee (7). A representative case is shown as (Table/Fig 1).

Lachman test: The Lachman test was done by flexing the knee to 20°. Afterwards, the distal thigh was grabbed by the examiner by one hand, and the proximal leg was grabbed by the other hand. Afterwards, anterior force was applied on leg. The positive Lachman test was indicated by abnormal forward movement and thus ACL injury (4). A representative case is shown as (Table/Fig 2).

Lever sign test: The lever sign test was done with patient in supine position and knees extended on a rigid surface. The examiner stood behind the patient, and closed fist was placed beneath the proximal third of the posterior leg, causing a minor knee flexion. Moderate force was applied with other hand on the distal third of the thigh of patient from anterior to posterior. When passive elevation of the heel does not occur in reference to the plane of the examination table, the test is termed positive. The test was considered negative with the heel rise and thus the ACL was taken into account as intact (9). A representative case is shown as (Table/Fig 3).

Positivity of the tests indicated that ACL tear was present while negative test indicated that there was no ACL tear.

Anaesthesia: The patient received a dose of intravenous cefuroxime (1.5 g) at the time of induction of anaesthesia. After the administration of anaesthesia, the patient was positioned supine on the operation table, the three tests were performed again and the results were recorded.

Then a tourniquet was tied around the thigh. The limb was painted and then draped in the standard fashion for knee arthroscopy. The tourniquet was inflated after exsanguinating the limb. Following this, a diagnostic arthroscopy was done and intraoperative findings {medial meniscal tears (current), lateral meniscal tears (current), cartilage injury} were recorded in recorder and ACL was repaired with gracilis hamstring autograft in case of ACL injury (14).

Statistical Analysis

The data was entered in Microsoft (MS) Excel spreadsheet and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0, International Business Machines (IBM) manufacturer, Chicago, United States of America (USA). Categorical variables were presented in number and percentage (%). Positivity and negativity of the tests were used to calculate sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) for predicting the ACL tears by using chi-square test. The p-value <0.05 was considered significant.

Results

Out of total 50 patients, 54% were in the age group 26-40 years, 28% in age <26 years, and 18% in >40 years. The mean age of the patients was 34.5±2.6 years. There were 60% males (n=30) and 40% females (n=20) (Table/Fig 4).

Sports injury was the most common injury in 24 (48%) patients, followed by fall 13 (26%), road traffic accident 9 (18%), and direct blow in 4 (8%) patients. In 29 (58%) patients, right-side was affected. In majority of the patients 17 (34%) since injury was <3 months, >6-9 months in 10 (20%), and 3-6 months in 9 (18%) patients. Medial meniscus injury was present in 21 (42%) patients, isolated ACL in 9 (18%), and lateral meniscus in 16 (32%) patients (Table/Fig 5).

Among the study patients, Mode of anaesthesia was spinal in 64% (n=32) of patients and spinal and epidural in 36% (n=18) of patients. The postoperative clinical features seen among the patients were numbness 3 (6%), swelling, effusion and pain in 2 (4%) patients each and local infection in only 1 (2%) of the patients. Range of motion at the time of enrolment was 40-50 degrees.

Accuracy of the tests for predicting the ACL tears: Sensitivity, Specificity, PPV, NPV, and diagnostic accuracy of anterior drawer test preanaesthesia were 83%, 87%, 97%, 50%, and 84%, respectively, and postanaesthesia were 88%, 87%, 97%, 58%, and 88%.

Sensitivity, Specificity, PPV, NPV, and diagnostic accuracy of Lachman test preanaesthesia were 88%, 87%, 97%, 58%, and 88%, respectively, and postanaesthesia were 90%, 87%, 97%, 63%, and 90%. Sensitivity, Specificity, PPV, NPV, and diagnostic accuracy of Lever sign test preanaesthesia were 85%, 88%, 100%, 57%, and 88%, respectively, and postanaesthesia were 88%, 100%, 100%, 61%, and 90% (Table/Fig 6).

There was no significant difference in the diagnostic accuracy of the three tests while comparing for paranaesthesia and post anaesthesia or for individual tests (p>0.05) (Table/Fig 7).

All the patients recovered postoperatively with a good range of motion of the knee as it increased from 40-50 degrees preoperatively upto 70-85 degrees, postoperatively.

Discussion

In this study, comparison of Lever sign test with anterior drawer test and Lachman test in case of ACL tear was done. The findings showed that lever sign test is highly sensitive and specific for predicting ACL injury but the diagnostic accuracy of all the tests were comparable with no statistically significant difference. The present study findings are partially in line with the studies by Deveci A et al., and Lelli A et al., who reported that as compared to the anterior drawer, Lachman, and pivot-shift tests, the lever sign test was more sensitive in diagnosing both acute and chronic ACL tears, as well as complete and partial ACL tears (9),(15).

Previously, Gürpinar T et al., Deveci A et al., Logan MC et al., Kim SJ and Kim HK, reported that the Lachman test was most accurate and reliable for diagnosis of an ACL rupture; and the pivot-shift test was reported to be the least sensitive of the three (13),(15),(16),(17). A study by Jarbo KA et al., found that the lever sign test was less accurate compared to the Lachman test (18). Though the results were consistent to findings of previous studies in terms of Lachman and anterior drawer tests accuracy, but Lever test showed higher accuracy as compared to other tests.

According to a meta-analysis including 16 studies, overall sensitivity and specificity of anterior drawer test were 0.725 and 0.927, respectively and that of the Lachman test were 0.871 and 0.97, respectively (19). Massey PA et al., showed sensitivity and specificity of anterior drawer test to be 82% and 80%, respectively; sensitivity and specificity of Lachman test were 89 and 85, respectively (20). These findings are similar to results of the present study for the Lachman test and anterior drawer test.

It is difficult to diagnose acute ACL injuries because of the associated pain, haemarthrosis, reactive synovitis, and swelling (21). For acute injuries, the sensitivity of Lachman test and the anterior drawer test as reported in literature was 0.78 and 0.22, respectively (22). Though in the study by Lelli A et al., sensitivity of the lever sign test was 100% for acute injuries (9). Presently, only few studies have examined the sensitivity of the lever sign test in acute injuries. History shows that for overcoming the lowered sensitivity of previously mentioned tests, Lelli A et al., in 2014 introduced the lever sign test specifically for acute ACL injuries (9).

Jarbo KA et al., evaluated the sensitivity and specificity of the lever sign test for the diagnosis of acute ACL injuries and found that lever sign test had 63% sensitivity and 90% specificity (18). Massey PA et al., reported that in acute cases the sensitivity of the lever sign test was 90% and the specificity was 77% (20).

It must be kept in mind that the two conditions which may affect the sensitivity of lever sign are partial tear of ACL and unreduced bucket handle tear of meniscus [10,20]. In partial tears, there are still some intact fibers which lift the tibia of the examination table and make test negative. In bucket handle tear, the meniscus get struck between the condyles and make test negative. Also, the factors such as patient resistance, pain, swelling, haemarthrosis, or time from the injury does not affect the sensitivity of the lever sign test. So, Lever test can be avoided in such cases and other tests can be employed (15).

Postanaesthesia, it was observed that the sensitivity of the anterior drawer test was altered the most. However, the change in sensitivity postanaesthesia was almost similar in lever sign and Lachman test. The specificity of anterior drawer and Lachman tests were similar postanaesthesia, while that of Lever sign increased from 88% to 100%. Overall there was no significant difference in the diagnostic accuracy before and after anaesthesia. In comparison, as reported by meta-analysis by van Eck CF et al., the sensitivity of the anterior drawer test increased from 38% to 63% postanaesthesia (23). In the study by Gürpinar T et al., the sensitivity of the Lachman and anterior drawer test increased from 83.9% to 89.7% and from 79.0% to 79.5%, respectively, postanaesthesia (13). However, there was no difference in the sensitivity of the lever sign test preanaesthesia and postanaesthesia (from 91.9% to 91.9%). Deveci AR et al., reported that postanaesthesia sensitivity of Lachman test increased from 80% to 88%, that of anterior drawer test increased from 60% to 88%, and that of lever sign test increased from 94% to 98% (Table/Fig 8) (15).

Based on the findings of the study, it has been demonstrated that accuracy of knee diagnostic tests rose slightly in terms of absolute values under anaesthesia, but it failed to cross statistical boundaries. This may suggest the significance of patient factor in the sensitivity of these tests which needs further validation (23). The sensitivity and specificity of these physical examination tests is influenced by several factors. Patients may be guarding because of pain as well as fear of subluxation. The physical exam may be obstructed by the concomitant injuries, like bucket handle meniscus tears leading to locking of the knee. Moreover, it is difficult to diagnose partial ruptures as compared to complete ruptures because of the stability provided by the remaining fibers (23). The comparative review of literature from similar studies has been summarised in (Table/Fig 8) (9),(10),(12),(13),(15),(17),(20).

The use of the combination of the three tests with first line test as lever sign test for diagnosing complete ACL tears, partial ACL tears, and multi-ligament knee injuries should be the focus of future research. Moreover, multicentric studies should be conducted for validating the use and practicality of these tests (after anaesthesia) for diagnosing ACL injuries.

Limitation(s)

The examiners in the present study were not blinded regarding the clinical history and side of the injury of patients. Also, partial, and complete tears were not distinguished in patients who underwent ACL reconstruction. Moreover, interobserver or intraobserver analyses were not performed. As lever sign test was done on the injured side only, thus it was not compared with healthy leg.

Conclusion

The lever test is an ideal test for diagnosing ACL injuries, and it is easily performed with high sensitivity, specificity, and diagnostic accuracy in the detection of ACL tears. Overall, lever test can be a good test for clinicians in acute, chronic and postreconstructive ACL injuries. All the three tests become more sensitive under anaesthesia for predicting ACL tears as it overcomes the patient related factors of fear and apprehension. This signifies the practical use of these tests after anaesthesia for better management of the patients.

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DOI and Others

DOI: 10.7860/JCDR/2022/51898.16277

Date of Submission: Aug 16, 2021
Date of Peer Review: Dec 11, 2021
Date of Acceptance: Feb 19, 2022
Date of Publishing: Apr 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Aug 17, 2021
• Manual Googling: Feb 08, 2022
• iThenticate Software: Mar 05, 2022 (25%)

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