Revisiting the Diagnostic Accuracy of Ottawa Ankle Rules for Ankle Fractures: A Systematic Review and Meta-Analysis Publisher



Razavi D S ; Seiri M ; Farrokhi M
Source: Archives of Academic Emergency Medicine Published:2026

Abstract

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. © 2026 Shaheed Beheshti University of Medical Sciences and Health Services. All rights reserved.