Stress Radiography for the Diagnosis of Knee Ligament Injuries: A Systematic Review

Clinical Orthopaedics and Related Research (Impact Factor: 2.79). 02/2014; 472(9). DOI: 10.1007/s11999-014-3470-8
Source: PubMed

ABSTRACT Stress radiography is a widely used diagnostic tool to assess injury to the anterior and posterior cruciate ligaments and the medial and lateral structures of the knee. However, to date, numerous techniques have been reported in the literature with no clear consensus as to which methodology is best for assessing ligament stability.
The purpose of this review was to identify which stress radiographic techniques have support in the literature for the diagnosis of acute or chronic knee ligament injuries, to define which technique is most accurate and reliable for diagnosing knee ligament injuries, and to compare the use of stress radiography with other diagnostic tests.
Two independent reviewers performed a systematic review of PubMed (MEDLINE), the EMBASE library, and the Cochrane Controlled Trials Register for English language studies published from January 1970 to August 2013 on the diagnosis of knee ligament injuries using stress radiography. Information describing the ligament(s) investigated, stress radiographic technique, magnitude of force, measures of accuracy and reliability, and comparative diagnostic tests were extracted. Risk of bias was assessed using the QUADAS-2 tool.
A total of 16 stress techniques were described for stress radiography of the knee. The diagnostic accuracy of stress radiography including the sensitivity, specificity, and positive and negative predictive values varied considerably depending on the technique and choice of displacement or gapping threshold. Excellent reliability was reported for the diagnosis of anterior cruciate ligament, posterior cruciate ligament, varus, and valgus knee injuries. Inconsistencies were found across studies regarding the efficacy of stress radiography compared with other diagnostic modalities.
Based on the multitude of stress techniques reported, varying levels of diagnostic accuracy, and inconsistencies regarding comparative efficacy of stress radiography to other diagnostic modalities, we are not able to make specific recommendations with regard to the best stress radiography technique for the diagnosis of knee ligament injuries. Additional comparative studies using consistent methodology and appropriate blinding are necessary to further define differences in accuracy and reliability both among stress radiography techniques and between stress radiography and other diagnostic tests.
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

  • [Show abstract] [Hide abstract]
    ABSTRACT: We have shown in a previous study that patients with combined lesions of the anterior cruciate (ACL) and medial collateral ligaments (MCL) had similar anteroposterior (AP) but greater valgus laxity at 30° after reconstruction of the ACL when compared with patients who had undergone reconstruction of an isolated ACL injury. The present study investigated the same cohort of patients after a minimum of three years to evaluate whether the residual valgus laxity led to a poorer clinical outcome. Each patient had undergone an arthroscopic double-bundle ACL reconstruction using a semitendinosus-gracilis graft. In the combined ACL/MCL injury group, the grade II medial collateral ligament injury was not treated. At follow-up, AP laxity was measured using a KT-2000 arthrometer, while valgus laxity was evaluated with Telos valgus stress radiographs and compared with the uninjured knee. We evaluated clinical outcome scores, muscle girth and time to return to activities for the two groups. Valgus stress radiographs showed statistically significant greater mean medial joint opening in the reconstructed compared with the uninjured knees (1.7 mm (SD 0.9) versus 0.9 mm (SD 0.7), respectively, p = 0.013), while no statistically significant difference was found between the AP laxity and the other clinical parameters. Our results show that the residual valgus laxity does not affect AP laxity significantly at a minimum follow up of three years, suggesting that no additional surgical procedure is needed for the medial collateral ligament in combined lesions.
    The Bone & Joint Journal 08/2011; 93(8):1060-4. DOI:10.1302/0301-620X.93B8.26183 · 2.80 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Seventy-one consecutive patients with posterolateral knee injuries had clinical stability testing abnormalities documented prospectively. We compared these findings with the incidence and patterns of their injuries documented at surgery. An abnormal reverse pivot shift test was associated with injury to the fibular collateral ligament (P = 0.01), popliteal components (P = 0.01), and midthird lateral capsular ligament (P = 0.02). An abnormal posterolateral external-rotation test at 30 degrees of flexion was associated with injury to the fibular collateral ligament (P = 0.0001) and lateral gastrocnemius tendon (P = 0.01). An abnormal adduction test at 30 degrees of flexion was associated with injury to the posterior arcuate ligament (P = 0.02). The results of this study should alert the clinician to the possibility of injury to a specific anatomic structure when the corresponding clinical stability test is abnormal. Because the fibular collateral ligament was injured in only 23% of the knees in this large series of patients, we recommend that an injury to the fibular collateral ligament not be the sole determining factor in making the diagnosis of posterolateral injuries. The wide array of injuries to many individual anatomic components that we found indicates the complexity of injuries to the posterolateral aspect of the knee.
    The American Journal of Sports Medicine 07/1997; 25(4):433-8. DOI:10.1177/036354659702500403 · 4.70 Impact Factor
  • Journal of Biomechanics 01/1985; 18(7):540-540. DOI:10.1016/0021-9290(85)90772-9 · 2.66 Impact Factor