Ottawa knee rule - Evidencio
Ottawa knee rule
The Ottawa knee rules were derived to aid in the efficient use of radiography in acute knee injuries.
The rule should be used in patients >2 years of age with knee pain/tenderness following trauma < 7 days ago.
Research authors: Stiell IG, Greenberg GH, Wells GA, McKnight RD, Cwinn AA, Cacciotti T, McDowell I, Smith NA.
Version: 1.12
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  • Orthopaedics
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Number of Ottawa knee rule criteria met: criteria

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How the Ottawa knee rule should be used:
The Ottawa knee rule was initially developed for patients >18 years of age with knee pain/tenderness following trauma < 7 days ago.1 The rule is sensitive (95-100%) to rule-out fractures, but not specific (19-50%) to suggest who may have a fracture. In a multicenter trial including 750 patients aged 2 to 16 years, Bulloch et al (2003) showed that the Ottawa ankle rule is also valid in children.2

Model performance:
In the derivation study (N=1,047) by Stiell et el (1995), the sensitivity of the Ottawa knee rule was 100% (95% confidence interval [CI], 95% to 100%) and specificity was 54% (95% CI, 51% to 57%).1 In a prospecitve validation (N=1096) by the same group, again a sensitivity of 100% (95% CI, 94% to 100%) was found.3 Upon external validation, independent research groups found sensitivities of 95-100% for clinically significant knee fractures using the Ottawa knee rule, with specificities ranging from 19-50%.4-7

Clinical implications of use:
According to the derivation study and several external validation studies, application of the rule would have led to a 17-49% relative reduction in the use of radiography.1-7 Successful use of the rule (e.g. by triage nurses) could improve patient flow, decrease waiting times, and allow for more efficient and cost-effective patient management.8

References:
1 Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use of radiography in acute knee injuries. Ann Emerg Med. 1995;26(4):405-13.
2 Bulloch B, Neto G, Plint A, et al. Validation of the Ottawa Knee Rule in children: a multicenter study. Ann Emerg Med. 2003;42(1):48-55.
3 Stiell IG, Greenberg GH, Wells GA, et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA. 1996;275(8):611-5.
4 Emparanza JI & Aginaga JR. Validation of the Ottawa Knee Rules. Ann Emerg Med. 2001;38(4):364-8.
5 Seaberg DC, Yealy DM, Lukens T, et al. 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.
6 Jalili M & Gharebaghi H. Validation of the Ottawa Knee Rule in Iran: a prospective study. Emerg Med J. 2010;27(11):849-51.
7 Tigges S, Pitts S, Mukundan S Jr, et al. 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.
8 Nichol G, Stiell IG, Wells GA, et al. An economic analysis of the Ottawa knee rule. Ann Emerg Med. 1999;34:438-47.
 

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