Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: a systematic review and meta-analysis

BACKGROUND: Ankle traumas are common presenting injuries to emergency departments in Australia and worldwide. The Ottawa Ankle Rules (OAR) are a clinical decision tool to exclude ankle fractures, thereby precluding the need for radiographic imaging in patients with acute ankle injury. Previous studies support the OAR as an accurate means of excluding ankle and midfoot fractures, but have included a paediatric population, report both the ankle and mid-foot, or are greater than 5 years old. This systematic review and meta-analysis aimed to update and assess the existing evidence of the diagnostic accuracy of the Ottawa Ankle Rule (OAR) acute ankle injuries in adults. METHODS: A systematic search and screen of was performed for relevant articles dated 1992 to 2020. Prospective and retrospective studies documenting OAR outcomes by physicians to assess ankle injuries were included. Critical appraisal of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Outcomes related to psychometric data were pooled using random effects or fixed effects modelling to calculate diagnostic performance of the OAR. Between-study heterogeneity was assessed using the Higgins I2 test, with Spearman’s correlation test for threshold effect. RESULTS: From 254 unique studies identified in the screening process, 15 were included, involving 8560 patients from 13 countries. Sensitivity, specificity, negative likelihood ratio, positive likelihood ratio and diagnostic odds ratio were 0.91 (95% CI, 0.89 to 0.92), 0.25 (95% CI, 0.24 to 0.26), 1.47 (95% CI, 1.11 to 1.93), 0.15 (95% CI, 0.72 to 0.29) and 10.95 (95% CI, 5.14 to 23.35) respectively, with high between-study heterogeneity observed (sensitivity: I2 = 94.3%, p < 0.01; specificity: I2 = 99.2%, p < 0.01). Most studies presented with low risk of bias and concern regarding applicability following assessment against QUADAS-2 criteria. CONCLUSIONS: Application of the OAR is highly sensitive and can correctly predict the likelihood of ankle fractures when present, however, lower specificity rates increase the likelihood of false positives. Overall, the use of the OAR tool is supported as a cost-effective method of reducing unnecessary radiographic referral, that should improve efficiency, lower medical costs and reduce waiting times. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12891-022-05831-7

Adequacy of clinical information in X-ray referrals for traumatic ankle injury with reference to the Ottawa Ankle Rules-a retrospective clinical audit

Study Objective To assess the adequacy of clinical information with reference to the Ottawa Ankle Rules (OAR) in X-ray referrals for adults with traumatic ankle injury in the ED of a South Australian tertiary hospital and report upon referring trends between emergency department clinicians. Methods A retrospective clinical audit of adult ankle X-ray referrals in the emergency department was conducted. Eligible referrals were screened for their adherence to the OAR, patient details, clinical history and referrer. A logistic regression was used to determine the influence of these factors on the likelihood of being referred for X-rays despite not meeting the OAR criteria. Sensitivity, specificity, positive and negative likelihood ratios and their associated confidence intervals were calculated to assess the diagnostic accuracy of the OAR for those referred. Results Out of the 262 eligible referrals, 163 were deemed to have met the criteria for the OAR. Physiotherapists showed the highest OAR compliance of 77.3% and were the most accurate in their use of the rules, with a sensitivity of 0.86. Medical officers, registrars and interns were 2.5 times more likely to still refer a patient for X-ray if they did not meet the OAR criteria, compared to physiotherapists as the baseline. Patient age, duration of injury etc. were not significantly associated with likelihood of referral (even when they did not meet OAR criteria). The overall sensitivity, specificity, positive and negative likelihood ratios of the OAR were 0.59 (95% CI [0.47–0.71]), 0.37 (95% CI [0.30–0.44]), 0.93 (95% CI [0.76–1.16]) and 1.10 (95% CI [0.82–1.48]) respectively. Conclusion The results of this audit demonstrated poor sensitivity and moderate compliance by referrers with the rule. Reasonable evidence exists for the implementation of individual and/or institutional-based change strategies to improve clinician compliance and accuracy with use of the OAR

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

The social, cultural and familial contexts contributing to childhood obesity

Extensive research on the social and environmental factors influencing childhood obesity over the past few decades offers a rich, biomedical, and social etiology that has not translated into successful prevention or treatment at the population level. Th

Gait and lower limb observation of paediatrics (GALLOP):Development of a consensus based paediatric podiatry and physiotherapy standardised recording proforma

BACKGROUND: Paediatric gait and lower limb assessments are frequently undertaken in podiatry and physiotherapy clinical practice and this is a growing area of expertise within Australia. No concise paediatric standardised recording proforma exists to assist clinicians in clinical practice. The aim of this study was to develop a gait and lower limb standardised recording proforma guided by the literature and consensus, for assessment of the paediatric foot and lower limb in children aged 0–18 years. METHOD: Expert Australian podiatrists and physiotherapists were invited to participate in a three round Delphi survey panel using the online Qualtrics(©) survey platform. The first round of the survey consisted of open-ended questions on paediatric gait and lower limb assessment developed from existing templates and a literature search of standardised lower limb assessment methods. Rounds two and three consisted of statements developed from the first round responses. Questions and statements were included in the final proforma if 70 % or more of the participants indicated consensus or agreement with the assessment method and if there was support within the literature for paediatric age-specific normative data with acceptable reliability of outcome measures. RESULTS: There were 17 of the 21 (81 %) participants who completed three rounds of the survey. Consensus was achieved for 41 statements in Round one, 54 statements achieved agreement in two subsequent rounds. Participants agreed on 95 statements relating to birth history, developmental history, hip measurement, rotation of the lower limb, ankle range of motion, foot posture, balance and gait. Assessments with acceptable validity and reliability were included within the final Gait and Lower Limb Observation of Paediatrics (GALLOP) proforma. CONCLUSION: The GALLOP proforma is a consensus based, systematic and standardised way to collect information and outcome measures in paediatric lower limb assessment. This standardised recording proforma will assist professions to collect information in a standardised format based on best evidence assessment methods whilst aiding consistency in communication between health professionals. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s13047-016-0139-4) contains supplementary material, which is available to authorized users