RESUMO
Introduction: In order to improve the efficacy of requesting knee radiography and reduce unnecessary radiation exposure, some clinical decision rules have been proposed for the assessment of knee injuries. Among them, the Ottawa Knee Rule (OKR) was considered as one of the best guidelines with several validation studies. Therefore, in this meta-analysis, we aimed to investigate the accuracy of OKR for diagnosis of fracture in patients presenting with knee trauma. Methods: A systematic search was conducted in PubMed, Web of Science, Scopus, Google Scholar, and EBSCO from inception to September 2022. Quality assessment of the included studies was performed using QUADAS-2 tool. Diagnostic accuracy parameters were analyzed using random-effects model. Statistical analysis was performed using Meta-Disc and Stata softwares. Results: The meta-analysis of the 18 included studies (6702 patients) showed that the pooled sensitivity and specificity of OKR for diagnosis of fractures were 0.98 (95% CI: 0.96-0.99) and 0.43 (95% CI: 0.42-0.45), respectively. The pooled positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 1.56 (95% CI: 1.39-1.75) and 0.12 (95% CI: 0.05-0.26), respectively. The area under curve (AUC) of the hierarchical summary receiver operating characteristic (HSROC) curve was 0.54. Conclusion: This meta-analysis indicates that OKR has a high diagnostic performance for diagnosis of fracture, with a pooled sensitivity of 98% and a pooled specificity of 43%. These results propose potential effects of OKR on reduction of unnecessary radiography, time spent in emergency departments, and direct and indirect costs, which should be confirmed using high-quality studies in the future.
RESUMO
Introduction: In spite of the results of previous studies regarding the benefits of ultrasonography for diagnosis of elbow fractures in children, the exact accuracy of this imaging modality is still under debate. Therefore, in this diagnostic systematic review and meta-analysis, we aimed to investigate the accuracy of ultrasonography in this regard. Methods: Two independent reviewers performed systematic search in Web of Science, Embase, PubMed, Cochrane, and Scopus for studies published from inception of these databases to May 2023. Quality assessment of the included studies was performed using Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2). Meta-Disc software version 1.4 and Stata statistical software package version 17.0 were used for statistical analysis. Results: A total of 648 studies with 1000 patients were included in the meta-analysis. The pooled sensitivity and specificity were 0.95 (95% CI: 0.93-0.97) and 0.87 (95% CI: 0.84-0.90), respectively. Pooled positive likelihood ratio (PLR) was 6.71 (95% CI: 3.86-11.67), negative likelihood ratio (NLR) was 0.09 (95% CI: 0.03-0.22), and pooled diagnostic odds ratio (DOR) of ultrasonography in detection of elbow fracture in children was 89.85 (95% CI: 31.56-255.8). The area under the summary receiver operating characteristic (ROC) curve for accuracy of ultrasonography in this regard was 0.93. Egger's and Begg's analyses showed that there is no significant publication bias (P=0.11 and P=0.29, respectively). Conclusion: Our meta-analysis revealed that ultrasonography is a relatively promising diagnostic imaging modality for identification of elbow fractures in children. However, clinicians employing ultrasonography for diagnosis of elbow fractures should be aware that studies included in this meta-analysis had limitations regarding methodological quality and are subject to risk of bias. Future high-quality studies with standardization of ultrasonography examination protocol are required to thoroughly validate ultrasonography for elbow fractures.