title: Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis.
abstract: OBJECTIVE
  To review the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules and explore if clinical features and/or methodological quality of the study influence diagnostic accuracy estimates.
  
  
  METHODS
  Systematic review with meta-analysis.
  
  
  METHODS
  MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library.
  
  
  METHODS
  Primary diagnostic studies reporting the accuracy of the Rules in people with ankle and/or midfoot injury were retrieved. Diagnostic accuracy estimates, overall and for subgroups (patient's age, profession of the assessor and setting of application), were made. Sensitivity analyses included studies with a low risk of bias and studies where all patients received radiographs.
  
  
  RESULTS
  66 studies were included. Ankle and Midfoot Rules presented similar accuracies, which were homogeneous and high for sensitivity and negative likelihood ratios and poor and heterogeneous for specificity and positive likelihood ratios (mean, 95% CI pooled sensitivity of Ankle Rules: 99.4%, 97.9% to 99.8%; specificity: 35.3%, 28.8% to 42.3%). Sensitivity of the Ankle Rules was higher in adults than in children, but the profession of the assessor did not appear to influence accuracy. Specificity was higher for Midfoot than for Ankle Rules. There were not enough studies to allow comparison according to setting of application. Studies with a low risk of bias and where all patients received radiographs provided lower accuracy estimates. Specificity heterogeneity was not explained by assessor training, use of imaging in all patients and low risk of bias.
  
  
  CONCLUSIONS
  Study features and the methodological quality influence estimates of the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules.
authors.affiliation: Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.|School of Science and Health, Western Sydney University, Australia.|Faculty of Health Sciences, The University of Sydney, New South Wales, Australia.
authors.forename: Paula R
authors.initials: PR
authors.lastname: Beckenkamp
authors.affiliation: Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
authors.forename: Chung-Wei Christine
authors.initials: CC
authors.lastname: Lin
authors.affiliation: School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.
authors.forename: Petra
authors.initials: P
authors.lastname: Macaskill
authors.affiliation: Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
authors.forename: Zoe A
authors.initials: ZA
authors.lastname: Michaleff
authors.affiliation: Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
authors.forename: Chris G
authors.initials: CG
authors.lastname: Maher
authors.affiliation: Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
authors.forename: Anne M
authors.initials: AM
authors.lastname: Moseley
mesh_terms: D000293:Adolescent; D000328:Adult; D016512:Ankle Injuries / Q000175:diagnosis*; D002648:Child; D003661:Decision Support Techniques; D018409:Foot Injuries / Q000175:diagnosis*; D006801:Humans; D008875:Middle Aged; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D055815:Young Adult
keywords: Ankle; Fracture; Injury; Sprain