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Revisiting the Diagnostic Accuracy of Ottawa Ankle Rules for Ankle Fractures: A Systematic Review and Meta-Analysis
Danial Sharifi Razavi1, Mohammadali Seiri2, Mehrdad Farrokhi3,4
1Department of Orthopedics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
Introduction:
The Ottawa Ankle Rules (OAR) have demonstrated conflicting results across studies, with generally high sensitivity but relatively low and variable specificity. This updated meta-analysis aims to evaluate the overall diagnostic characteristics of the OAR for early identification of ankle fractures in adult patients.
Methods:
In this systematic review and meta-analysis, a comprehensive literature search was conducted from database inception through May 2026 across three electronic databases, including Medline, Web of Science, and Scopus. The MIDAS package in STATA and Meta-Disc software were used to pool the findings of the diagnostic accuracy studies. Clinical application of the OAR was assessed using Fagan's nomogram and scattergram.
Results:
The pooled sensitivity and specificity of OAR were 0.92 (95% confidence interval (CI): 0.91-0.93) and 0.35 (95% CI: 0.34-0.36), respectively. The pooled positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 1.76 (95% CI: 1.46-2.13) and 0.13 (95% CI: 0.09-0.19), respectively. Furthermore, the pooled diagnostic odds ratio (DOR) was 16.21 (95% CI: 10.15-25.89).
Conclusion:
In conclusion, the OAR demonstrate excellent sensitivity and a very low negative likelihood ratio, confirming their value as a reliable screening tool for ruling out ankle fractures in clinical practice. With pooled sensitivities exceeding 90% and a post-test probability reduced to approximately 1% following a negative result, the OAR can safely reduce unnecessary radiographic imaging.
