ACCURACY OF THE LEVER SIGN TO DIAGNOSE ANTERIOR CRUCIATE LIGAMENT TEAR: A SYSTEMATIC REVIEW WITH META-ANALYSIS.

backgroundThe Lever sign has gained recent notoriety for its purported anterior cruciate ligament (ACL) diagnostics and simplicity of performance. PURPOSE: The purpose of this systematic review with meta-analysis is to summarize the diagnostic accuracy of the Lever sign for use during assessment of the knee for an ACL tear in subjects with suspected acute and chronic knee injury. STUDY

designSystematic review with meta-analysis.

methodsA computer-assisted literature search of MEDLINE, CINAHL, and EMBASE databases using keywords related to diagnostic accuracy of the knee joint. The

resultsEight articles, with only two demonstrating high quality, were included. Six of the articles were included in a meta-analysis. Diagnostic values, utilizing arthroscopy as a gold standard, were: pooled SN 0.55 (95% CI 0.22 to 0.84), pooled SP 0.89 (95% CI 0.44 to 0.99), positive likelihood ratio (+LR) 9.2 (95% CI 0.70 to 46.1), negative likelihood ratio (-LR) 0.58 (95% CI 0.18 to 1.28). Post-test probability with a positive finding (57% sampling prevalence) reached 92% (95% CI 83 to 97%). Post-test probability with a negative finding (57% sampling prevalence) reached 43% (95% CI 39 to 47%).

conclusionsBased on limited evidence of heterogeneous methodological quality, the Lever sign can moderately change post-test probability to rule in an ACL tear. These results should be interpreted cautiously due to a limited number of studies, with small sample sizes and study quality affecting test accuracy. Future investigation should be expanded to include additional high-quality studies examining diverse clinical contexts, as they become available, to enable a more comprehensive clinical examination of this test. LEVEL OF EVIDENCE: 3aPROSPERO Registration # CRD42018084954.