Diagnostic Accuracy of Ottawa Knee Rule for Diagnosis of Fracture in Patients with Knee Trauma; a Systematic Review and Meta-analysis
Archives of Academic Emergency Medicine,
Vol. 11 No. 1 (2023),
15 Aban 2022
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.
- Clinical decision rules
- Knee injuries
- Ottawa knee rule
How to Cite
Stiell IG, Wells GA, Hoag RH, Sivilotti ML, Cacciotti TF, Verbeek PR, et al. Implementation of the Ottawa Knee Rule for the use of radiography in acute knee injuries. JAMA. 1997;278(23):2075-9.
Stiell IG, Greenberg GH, Wells GA, McKnight RD, Cwinn AA, Cacciotti T, et al. Derivation of a decision rule for the use of radiography in acute knee injuries. Ann Emerg Med. 1995;26(4):405-13.
Keyhani S, Kazemi SM, Ahn JH, Verdonk R, Soleymanha M. Arthroscopic treatment of diffuse pigmented villonodular synovitis of the knee: complete synovectomy and septum removal—midterm results. J Knee Surg. 2019;32(05):427-33.
Kazemi SM, Minaei R, Safdari F, Keipourfard A, Forghani R, Mirzapourshafiei A. Supracondylar osteotomy in valgus knee: angle blade plate versus locking compression plate. Arch Bone Jt Surg. 2016;4(1):29.
Stiell IG, Wells GA, McDowell I, Greenberg GH, McKnight RD, Cwinn AA, et al. Use of radiography in acute knee injuries: need for clinical decision rules.
Acad Emerg Med. 1995;2(11):966-73.
Stiell IG, Greenberg GH, Wells GA, McDowell I, Cwinn AA, Smith NA, et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA. 1996;275(8):611-5.
Seaberg DC, Jackson R. Clinical decision rule for knee radiographs. Am J Emerg Med. 1994;12(5):541-3.
Seaberg DC, Yealy DM, Lukens T, Auble T, Mathias S. Multicenter comparison of two clinical decision rules for the use of radiography in acute, high-risk knee injuries.
Ann Emerg Med. 1998;32(1):8-13.
Mohamed A, Babikir E, Mustafa MKE. Ottawa Knee Rule: Investigating Use and Application in a Tertiary Teaching Hospital. Cureus. 2020;12(6):e8812.
Beutel BG, Trehan SK, Shalvoy RM, Mello MJ. The Ottawa knee rule: examining use in an academic emergency department. West J Emerg Med. 2012;13(4):366.
Emparanza JI, Aginaga JR. Validation of the Ottawa knee rules. Ann Emerg Med. 2001;38(4):364-8.
Ketelslegers E, Collard X, Vande Berg B, Danse E, El Gariani A, Poilvache P, et al. Validation of the Ottawa knee rules in an emergency teaching centre. Eur Radiol. 2002;12(5):1218-20.
Bachmann LM, Haberzeth S, Steurer J, ter Riet G. The accuracy of the Ottawa knee rule to rule out knee fractures: a systematic review. Ann Intern Med. 2004;140(2):121-4.
Atkinson P, Boyle A, Chisholm E. X-ray requesting patterns before and after introduction of the Ottawa Knee Rules in a UK emergency department. Eur J Emerg Med. 2004;11(4):204-7.
Vijayasankar D, Boyle A, Atkinson P. Can the Ottawa knee rule be applied to children? A systematic review and meta-analysis of observational studies. Emerg Med J. 2009;26(4):250-3.
Sims JI, Chau MT, Davies JR. Diagnostic accuracy of the Ottawa Knee Rule in adult acute knee injuries: a systematic review and meta-analysis. Eur Radiol. 2020;30:4438-46.
Sims JI, Chau M, Davies J. Validation of the Ottawa knee rule in adults: A single centre study. J Med Radiat Sci. 2020;67(3):193-8.
Vahdati SS, Ala A, Samani Z, Ahari SG, Mirza-Aghazadeh-Attari M. Screening of Trauma Patients in Need of Knee Radiography by Triage Nurses and Using Ottawa Knee Rule; a Letter to Editor. Arch Acad Emerg Med. 2019;7(1):e57.
Cheung TC, Tank Y, Breederveld RS, Tuinebreijer WE, de Lange-de Klerk ES, Derksen RJ. Diagnostic accuracy and reproducibility of the Ottawa Knee Rule vs the Pittsburgh Decision Rule. Am J Emerg Med. 2013;31(4):641-5.
Konan S, Zang T, Tamimi N, Haddad F. Can the Ottawa and Pittsburgh rules reduce requests for radiography in patients referred to acute knee clinics? Ann R Coll Surg Engl. 2013;95(3):188-91.
Jalili M, Gharebaghi H. Validation of the Ottawa knee rule in Iran: a prospective study. Emerg Med J. 2010;27(11):849-51.
Kec RM, Richman PB, Szucs PA, Mandell M, Eskin B. Can emergency department triage nurses appropriately utilize the Ottawa Knee Rules to order radiographs? An implementation trial. Acad Emerg Med. 2003;10(2):146-50.
Matteucci MJ, Roos JA. Ottawa Knee Rule: a comparison of physician and triage-nurse utilization of a decision rule for knee injury radiography. J Emerg Med. 2003;24(2):147-50.
Szucs PA, Richman PB, Mandell M. Triage nurse application of the Ottawa knee rule. Acad Emerg Med. 2001;8(2):112-6.
Tigges S, Pitts S, Mukundan Jr S, Morrison D, Olson M, Shahriara A. External validation of the Ottawa knee rules in an urban trauma center in the United States. AJR Am J Roentgenol. 1999;172(4):1069-71.
Richman PB, McCuskey CF, Nashed A, Fuchs S, Petrik R, Imperato M, et al. Performance of two clinical decision rules for knee radiography. J Emerg Med. 1997;15(4):459-63.
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