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V. Bélanger et al.
The aim of this study was to determine the diagnostic
accuracy of: (i) diagnostic HRUS for detecting LHBT
tendinopathy, dislocation, rupture (partial or complete)
and bicipital recess effusion; and (ii) OSTs for detecting
any pathology of the LHBT in patients with shoulder
pain. The study determined the accuracy of each OST
related to LHBT, for detecting the specific clinical
entity for which they were designed (Appendix I) (14).
METHODS
Criteria for considering studies for this review
Included studies were prospective, either delayed cross-sectio-
nal or diagnostic case-control studies, which included patients
recruited in primary, secondary or tertiary care settings. There
was no limit to sample sizes or prevalence in the included
studies; however, 100% prevalence studies were eliminated
because they do not allow calculation of specificity.
Participants
Any patients with shoulder pain were considered, with no limit
on diagnosis or age group. However, studies including exclu-
sively rheumatological or neurological populations were not
considered, since these disorders encompass a diverse group
of musculoskeletal conditions that differ from those found in
the general population.
Index tests
OSTs (Appendix I) and HRUS were the index tests. HRUS
methods for examining the LHBT had to be congruent with
accepted standards (15, 16).
Target conditions
SLAP lesions, tendinopathy, dislocation, rupture and effusion
(bicipital recess) of the LHBT were considered.
Reference standards
HRUS had to be compared with surgery (open or arthroscopy),
magnetic resonance (MR) imaging or MR arthrography. OSTs
had to be compared with surgery, HRUS, MR imaging or MR
arthrography.
Search methods for identification of studies
MEDLINE, CINAHL and EMBASE databases were searched
for eligible articles from their inception dates to July 2018.
Articles had to be written in French or English. The full search
strategy is described in Appendix II. The reference lists for every
article found in the original electronic search were screened to
identify further eligible articles.
Data collection and analysis
Selection of studies. Two review authors independently selected
the studies. In case of disagreement, a third author was involved
to reach consensus. Articles were selected if they met the selection
criteria for population, index test, reference standard, and reported
on the diagnostic accuracy of individual index tests for diagnosing
a specific LHBT pathology (SLAP lesions, LHBT tendinopathy,
dislocation, rupture or effusion). We started with a review of titles,
proceeded to abstracts where titles indicated possibly relevant
studies, and selected eligible studies after reading their full text.
Data extraction and management. Data were extracted by 2
independent authors. If any disagreement occurred during this
step, a third reviewer intervened to reach mutual agreement. The
extraction decision was based on the possibility of drawing a
2 × 2 table. If the tables were not included in the article, data allo-
wing reconstruction was necessary. If there was any discrepancy
between text and tables, articles were removed from analysis
unless original authors could be contacted to resolve the issue.
Quality assessment. The risk of bias of each study was assessed
using Quality Assessment Tool for Diagnostic Accuracy Studies
(QUADAS-2) by the same 2 independent authors who selected
the studies and extracted the data (17). This tool is designed to
appraise studies’ selection bias and information bias by assessing
4 key domains: patient selection; index test; reference standard;
flow of patients through the study and timing of the index test(s)
and reference standard. Results are expressed in terms of the
methodological quality “high”, “low” or “unclear”, based on
the author’s judgement. Authors of reviews are encouraged to
tailor QUADAS-2 to their review by developing review-specific
guidance on how to assess each signalling question (17). In that
respect, after consensus among authors, specific criteria were used
for each section (Table I). Gwet’s first-order agreement coefficient
(Gwet’s AC1) was used to calculate interobserver agreement (18).
Statistical analysis and data synthesis
A systematic review should not culminate in meta-analysis
if there are differences between the studies in terms of the
Table I. Quality assessment tool for diagnostic accuracy studies (QUADAS-2) items’ specifications developed by authors of the review
QUADAS-2 item Specifications
Patient selection Study samples had to include unrestricted population of patients with shoulder pain. If the inclusion criteria were too specific, we
considered a high risk of bias.
Had to be described, or at least, referenced. If neither of those, we attributed a high risk of bias.
The following reference standards were considered adequate for each LHBT pathology (2):
Index tests
Reference standards
SLAP lesion: histopathology, open surgery, arthroscopy and MR arthrography;
LHBT tendinopathy: histopathology and open surgery;
LHBT rupture or dislocation: histopathology, open surgery, arthroscopy, MR imaging/arthrography and HRUS.
Flow and timing
If the reference standard used in the study was not in this list, it was considered an unclear risk of bias.
A 1-month period in between the index test and reference standard was considered adequate. We chose this cut-off to minimize disease
progression bias, since tendon condition can evolve over time. We are aware that some authors (58) consider an 8-month period as a
cut-off, but this seems too long.
LHBT: long head of the biceps tendon; SLAP: superior labrum anterior and posterior; MR: magnetic resonance; HRUS: high-resolution ultrasound.
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