Seeber Gesine H, Thalhamer Christoph, Matthijs Omer C, Doskar Wolfgang, Sizer Phillip S, Lazovic Djordje
University Hospital for Orthopaedics and Trauma Surgery Pius-Hospital, Medical Campus University of Oldenburg, Georgstr. 12, 26121, Oldenburg, Germany.
Gelenkspezialisten, Specialist Center for Orthopedics, Trauma Surgery and Rehabilitation, Vienna, Austria.
Sports Med Open. 2022 Aug 19;8(1):106. doi: 10.1186/s40798-022-00500-4.
Commonly used clinical posterior cruciate ligament (PCL) tests present with diagnostic weaknesses requiring alternative clinical tests. The Lateral-Anterior Drawer test (LAD-test) is a suggested alternative that previously demonstrated concurrent validity in situ. Further in vivo LAD-test clinical accuracy examination is required prior to any recommendation for clinical adoption. Thus, this case-control study aims to (1) investigate the LAD-test's in vivo interrater and intra-rater reliability; (2) establish LAD-test concurrent validity against MRI as the reference standard; and (3) examine the correspondence between examiners' professional working experience and LAD-test diagnostic accuracy.
Three examiners with different professional experience levels, blindfolded during testing, and blinded from subjects' identity, medical history, and reference test outcome performed all LAD-testing twice per subject. Reliability analyses included percent agreement, Fleiss' kappa and Cohen's kappa coefficients with 95% Confidence Intervals (CIs) and prevalence-adjusted bias-adjusted kappa (PABAK) calculations. Validation parameters included sensitivity, specificity, likelihood ratios (LR + ; LR-), and predictive values (PPV; NPV) each accompanied by 95%CIs; each tester's percent agreement with the MRI; and their Youden Index.
The study sample was comprised of 31 subjects of which 14 had a history of unilateral full-thickness PCL-rupture. Their 14 contralateral knees and both knees of 17 healthy subjects served as controls. In vivo LAD-test performance did not produce any negative ramifications for the tested subjects. Interrater reliability was moderate (test-1: Fleiss'κ = 0.41; 95% CI 0.40;0.41; test-2:Fleiss'κ = 0.51; 95% CI 0.50;0.51). Pairwise examiner's LAD-test outcome agreement ranged from 74 to 89%. Pairwise interrater reliability was fair-to-substantial (κ = 0.27 to κ = 0.65) with moderate-to-substantial PABAK (0.48-0.77). Intra-rater reliability was substantial-to-almost perfect (PABAK 0.65-0.97). Sensitivity and specificity ranged from 57 to 86% and 83 to 98%, respectively. The advanced and novice clinicians' Youden Indexes were acceptable. The same examiners' positive likelihood ratios revealed important and relative important effects, respectively. Positive predictive values were considerable for the advanced and novice clinicians, while negative predictive values were high for all examiners.
Overall, the study results suggested LAD-test practicability. In vivo LAD-test performance did not produce any negative ramifications for the tested subjects. In subjects presenting with a chronic PCL-deficiency (i.e., > 3 months since initial injury), the LAD-test's clinical accuracy was comparable-to-superior to other commonly used clinical PCL-tests. Future studies to establish the LAD-test's usefulness in isolation as well as in combination with other clinical tests for acute PCL-rupture diagnostics are warranted.
DRKS00013268 (09. November 2017).
常用的临床后交叉韧带（PCL）检查存在诊断缺陷，需要其他临床检查方法。外侧 - 前抽屉试验（LAD试验）是一种建议采用的替代方法，此前已证明其在原位具有同时效度。在推荐临床应用之前，需要进一步进行LAD试验的体内临床准确性检查。因此，本病例对照研究旨在：（1）调查LAD试验在体内的评分者间和评分者内信度；（2）以MRI作为参考标准建立LAD试验的同时效度；（3）检查检查者的专业工作经验与LAD试验诊断准确性之间的对应关系。
三名具有不同专业经验水平的检查者在测试过程中蒙眼，并对受试者的身份、病史和参考测试结果不知情，对每个受试者进行两次LAD试验。信度分析包括一致性百分比、Fleiss卡方和Cohen卡方系数以及95%置信区间（CIs），并计算患病率调整偏差调整卡方（PABAK）。效度参数包括敏感性、特异性、似然比（LR +；LR -）和预测值（PPV；NPV），每个参数都伴有95% CIs；每个测试者与MRI的一致性百分比；以及他们的约登指数。
研究样本包括31名受试者，其中14名有单侧PCL全层断裂病史。他们的14个对侧膝关节和17名健康受试者的双侧膝关节作为对照。LAD试验在体内的表现对受试对象没有产生任何负面影响。评分者间信度为中等（测试1：Fleiss'κ = 0.41；95% CI 0.40；0.41；测试2：Fleiss'κ = 0.51；95% CI 0.50；0.51）。检查者之间LAD试验结果的两两一致性范围为74%至89%。两两评分者间信度为一般至较高（κ = 0.27至κ = 0.65），PABAK为中等至较高（0.48 - 0.77）。评分者内信度为较高至几乎完美（PABAK 0.65 - 0.97）。敏感性和特异性分别为57%至86%和83%至98%。经验丰富的临床医生和新手临床医生的约登指数均可接受。相同检查者的阳性似然比分别显示出重要和相对重要的效应。经验丰富的临床医生和新手临床医生的阳性预测值可观，而所有检查者的阴性预测值都很高。
总体而言，研究结果表明LAD试验具有实用性。LAD试验在体内的表现对受试对象没有产生任何负面影响。在患有慢性PCL缺陷（即自初次受伤以来超过3个月）的受试者中，LAD试验的临床准确性与其他常用的临床PCL检查相当甚至更优。有必要开展进一步研究，以确定LAD试验单独使用以及与其他临床检查联合用于急性PCL断裂诊断的有效性。
DRKS00013268（2017年11月9日）
