Towards improving the identification of anterior cruciate ligament tears in primary point-of-care settings.

BACKGROUND: Only a small proportion of anterior cruciate ligament (ACL) tears are diagnosed on initial healthcare consultation. Current clinical guidelines do not acknowledge that primary point-of-care practitioners rely more heavily on a clinical history than special clinical tests for diagnosis of an ACL tear. This research will assess the accuracy of combinations of patient-reported variables alone, and in combination with clinician-generated variables to identify an ACL tear as a preliminary step to designing a primary point-of-care clinical decision support tool. METHODS: Electronic medical records (EMRs) of individuals aged 15-45 years, with ICD-9 codes corresponding to a knee condition, and confirmed (ACL+) or denied (ACL-) first-time ACL tear seen at a University-based Clinic between 2014 and 2016 were eligible for inclusion. Demographics, relevant diagnostic indicators and ACL status based on orthopaedic surgeon assessment and/or MRI reports were manually extracted. Descriptive statistics calculated for all variables by ACL status. Univariate between group comparisons, clinician surveys (n = 17), availability of data and univariable logistic regression (95%CI) were used to select variables for inclusion into multivariable logistic regression models that assessed the odds (95%CI) of an ACL-tear based on patient-reported variables alone (consistent with primary point-of-care practice), or in combination with clinician-generated variables. Model performance was assessed by accuracy, sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios (95%CI). RESULTS: Of 1512 potentially relevant EMRs, 725 were included. Participant median age was 26 years (range 15-45), 48% were female and 60% had an ACL tear. A combination of patient-reported (age, sport-related injury, immediate swelling, family history of ACL tear) and clinician-generated (Lachman test result) variables were superior for ACL tear diagnosis [accuracy; 0.95 (90,98), sensitivity; 0.97 (0.88,0.98), specificity; 0.95 (0.82,0.99)] compared to the patient-reported variables alone [accuracy; 84% (77,89), sensitivity; 0.60 (0.44,0.74), specificity; 0.95 (0.89,0.98)]. CONCLUSIONS: A high proportion of individuals without an ACL tear can be accurately identified by considering patient-reported age, injury setting, immediate swelling and family history of ACL tear. These findings directly inform the development of a clinical decision support tool to facilitate timely and accurate ACL tear diagnosis in primary care settings.

Team-based musculoskeletal assessment and healthcare quality indicators: A systematic review.

The primary objective of this review was to describe health quality indicator (HQI) outcomes of team-based musculoskeletal (MSK) assessments aimed at directing patient care. Secondary objectives included determining the most commonly assessed HQIs, extent of team collaboration, and the healthcare practitioners that most commonly comprise MSK-assessment teams. This review was registered in the PROSPERO database and conducted according to PRISMA guidelines. Five databases were systematically searched to August 2017. Studies selected met a priori inclusion criteria and investigated an HQI outcome of a primary or intermediate care MSK team-based assessment aimed at directing treatment. Two independent raters assessed study quality [Downs and Black (DB) criteria] and level of evidence (Oxford Centre of Evidence-Based Medicine model). Ten studies were included. The majority were low-quality [median DB score 14/32 (range 6-18)] pre-experimental studies (level 4 evidence). Heterogeneity in methodology and HQIs precluded meta-analyses. Hospital length-of-stay (LOS; 3/10 studies) and pain level (3/10) were the most common HQIs investigated. Teams (9/10) were most commonly comprised of a physiotherapist and another healthcare practitioner. Most teams (8/10) demonstrated low-levels of collaboration. There is limited low-level evidence to suggest that team-based MSK assessments are associated with improved clinical outcomes (i.e., pain, quality-of-life) and shorter LOS.

A Pilot Study Evaluating the Effectiveness of Platelet-Rich Plasma Therapy for Treating Degenerative Tendinopathies: A Randomized Control Trial with Synchronous Observational Cohort.

OBJECTIVE: This pilot study aimed to inform future research evaluating the effectiveness of Platelet Rich Plasma (PRP) injection for tendinopathy. DESIGN: Randomized control trial (RCT) and synchronous observational cohort studies. For the RCT, consecutive consenting patients treated at an academic sports medicine clinic were randomly assigned to either a PRP or placebo control group. SETTING: The Glen Sather Sport Medicine Clinic, Edmonton, Canada. PATIENTS: The RCT included 9 participants with rotator cuff tendinopathy. The cohort study included 178 participants with a variety of tendinopathies. INTERVENTIONS: Patients receiving PRP were injected with 4 ml of platelets into the supraspinatus and/or infraspinatus, while patients in the placebo group were injected with 4 ml of saline. All participants undertook a 3-month standardized, home-based, daily exercise program. MAIN OUTCOME MEASURES: Participants in the RCT were re-evaluated 3, and 6 months post-injection. Change scores before and after injection on pain, disability and MRI-documented pathology outcomes were compared. In the cohort study, pain and disability were measured at 1, 2 and 3 months post-injection. RESULTS: For the RCT, 7 participants received PRP and 2 received placebo injections. Patients receiving PRP reported clinically important improvements in pain (>1.5/10 on VAS), disability (>15 point DASH change), and tendon pathology while those receiving placebo injections did not. In the observational cohort, statistically and clinically significant improvements in pain and disability were observed. CONCLUSION: This pilot study provides information for planning future studies of PRP effectiveness. Preliminary results indicate intratendinous, ultrasound-guided PRP injection may lead to improvements in pain, function, and MRI-documented tendon pathology. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN68341698.