Diagnosing Achilles Tendon Rupture with Ultrasound in Patients Treated Surgically: A Systematic Review and Meta-Analysis.

BACKGROUND: Achilles tendon rupture is a common injury with increasing incidence due to the rising popularity of high-velocity sports, continued physical activity of the aging American population, and use of fluoroquinolones and steroid injections. The diagnosis can often be missed or delayed, with up to 20% misdiagnosed, most commonly as an ankle sprain. OBJECTIVE: The aim of our study was to systematically evaluate the reported sensitivity, specificity, and likelihood ratios of ultrasound for detecting Achilles tendon rupture in patients who were treated surgically. METHODS: In January 2020, we performed a literature search of MEDLINE and EMBASE databases to identify eligible articles according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were original studies with at least five patients, which reported data on the sonographic diagnosis of Achilles tendon rupture (complete or partial) compared to surgery as the reference standard. RESULTS: A total of 15 studies with 808 patients were included in the primary analysis. The sensitivity of ultrasound for detecting complete Achilles tendon ruptures was 94.8% (95% confidence interval [CI] 91.3-97.2%), specificity was 98.7% (95% CI 97.0-99.6%), positive likelihood ratio was 74.0 (95% CI 31.0-176.8), and negative likelihood ratio was 0.05 (95% CI 0.03-0.09), in patients who underwent surgical treatment. CONCLUSIONS: The results from our study suggested that a negative ultrasound result may have the potential to rule out a complete, as well as a partial, Achilles tendon rupture.

Interpretation Accuracy and Interrater Agreement of Pediatric Skin and Soft Tissue Point-of-Care Ultrasound Images among Residents and Faculty.

BACKGROUND: Point-of-care ultrasound (POCUS) is commonly used to facilitate care in the emergency department. Acquired images are often reviewed by local experts for educational and quality assurance purposes. However, no published study has examined the accuracy and reliability of POCUS image interpretation by multiple reviewers. OBJECTIVES: We studied the accuracy and interrater agreement among expert and trainee reviewers of prerecorded pediatric skin and soft tissue (SST) POCUS images. METHODS: POCUS faculty and emergency medicine (EM) residents blindly reviewed deidentified pediatric SST POCUS images and indicated whether a drainable fluid collection was present, absent, or indeterminate. This was then compared with the gold standard based on discharge diagnoses and telephone follow-up. Images rated as indeterminate were excluded from the initial analysis. Sensitivity analysis assuming indeterminate answers were inaccurate was subsequently conducted. RESULTS: In phase 1, 6 pediatric EM POCUS directors reviewed 168 images. The overall accuracy was 79.7% (range 66.1-86.0%). The mean Cohen's kappa was 0.58 (range 0.24-0.84). Sensitivity analysis yielded an overall accuracy of 71.3% (range 56.5-76.9%) and a Cohen's kappa of 0.43 (range 0.20-0.59). In phase 2, 6 general EM POCUS faculty and 20 EM residents reviewed 120 images. The overall accuracy among residents was 72.2% (range 51.4-84.7%) and among faculty was 83.6% (range 77.9-88.8%). Sensitivity analysis yielded an overall resident accuracy of 63.0% (range 49.5-80.7) and an overall faculty accuracy of 73.9% (range 67.0-79.8%). Fleiss' kappa was 0.322 for residents and 0.461 for faculty. CONCLUSIONS: We found moderate accuracy and fair to good interrater agreement among POCUS faculty and EM residents reviewing pediatric SST POCUS images.